Provider Demographics
NPI:1720650476
Name:OPTIMUM MEDICAL SUPPLY CORPORATION
Entity Type:Organization
Organization Name:OPTIMUM MEDICAL SUPPLY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANETT
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZUELA AYUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-283-2391
Mailing Address - Street 1:964 5TH AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6102
Mailing Address - Country:US
Mailing Address - Phone:858-283-2391
Mailing Address - Fax:
Practice Address - Street 1:3200 4TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5716
Practice Address - Country:US
Practice Address - Phone:858-283-2391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-13
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies