Provider Demographics
NPI:1912389636
Name:OPT2GO OUTLET INC
Entity Type:Organization
Organization Name:OPT2GO OUTLET INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:Q
Authorized Official - Last Name:MIU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-653-8836
Mailing Address - Street 1:219 CANAL ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:219 CANAL ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-4114
Practice Address - Country:US
Practice Address - Phone:646-476-3021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00-8841305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000000Medicaid
NY00000000OtherI AM APPLYING FOR MEDICAID, SO I DON'T KNOW THE ID NUMBER UNTIL I GET A NPI.