Provider Demographics
NPI:1942604723
Name:OPTIMAL JACKSONVILLE LLC
Entity Type:Organization
Organization Name:OPTIMAL JACKSONVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:HALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-429-0957
Mailing Address - Street 1:3803 BEDFORD AVE
Mailing Address - Street 2:#103
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2564
Mailing Address - Country:US
Mailing Address - Phone:904-733-7770
Mailing Address - Fax:
Practice Address - Street 1:6138 KENNERLY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4393
Practice Address - Country:US
Practice Address - Phone:904-733-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty