Provider Demographics
NPI:1750883062
Name:OPTIMAL SUPPORT FOR EVERYDAY LIVES
Entity type:Organization
Organization Name:OPTIMAL SUPPORT FOR EVERYDAY LIVES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:MATTAR
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-764-3788
Mailing Address - Street 1:5800 SPRINGFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143
Mailing Address - Country:US
Mailing Address - Phone:484-764-3788
Mailing Address - Fax:
Practice Address - Street 1:5800 SPRINGFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143
Practice Address - Country:US
Practice Address - Phone:484-764-3788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========Medicaid