Provider Demographics
NPI:1710393392
Name:OPTUM CLINIC PA
Entity Type:Organization
Organization Name:OPTUM CLINIC PA
Other - Org Name:OPTUM CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-732-7325
Mailing Address - Street 1:PO BOX 692
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0692
Mailing Address - Country:US
Mailing Address - Phone:877-456-5506
Mailing Address - Fax:
Practice Address - Street 1:69 S VALLE VERDE DR.
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012
Practice Address - Country:US
Practice Address - Phone:877-456-5506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-03
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care