Provider Demographics
NPI:1730654021
Name:OPTIMOM HEALTHCARE LLC
Entity Type:Organization
Organization Name:OPTIMOM HEALTHCARE LLC
Other - Org Name:OPTIMOM HEALTHCARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANGURA
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:281-905-8277
Mailing Address - Street 1:6119 KNOLLWEST DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77072-1021
Mailing Address - Country:US
Mailing Address - Phone:832-672-4903
Mailing Address - Fax:
Practice Address - Street 1:6119 KNOLLWEST DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-1021
Practice Address - Country:US
Practice Address - Phone:832-672-4903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-12
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHHS000004900867Other001031105
TX648953782OtherSECRETARY OF STATE