Provider Demographics
NPI:1669602165
Name:OPTUM INFUSION SERVICES 402, LLC
Entity type:Organization
Organization Name:OPTUM INFUSION SERVICES 402, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:1 OPTUM CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:800-328-5979
Mailing Address - Fax:
Practice Address - Street 1:2300 MAIN ST STE 150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6223
Practice Address - Country:US
Practice Address - Phone:562-263-5600
Practice Address - Fax:866-476-2489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCP SPECIALTY INFUSION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-17
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHY57578OtherSTATE PHARMACY LICENSE
6368790001Medicare NSC