Provider Demographics
NPI:1659906519
Name:OPTIMUM IOM PRO, LLC
Entity Type:Organization
Organization Name:OPTIMUM IOM PRO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISAMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARTRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-412-5299
Mailing Address - Street 1:3526 LAKEVIEW PKWY # B132
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22841 COLORADO DR
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365-3635
Practice Address - Country:US
Practice Address - Phone:281-772-9023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Single Specialty