Basic Information
| Provider Information | |||||||||
| NPI: | 1073992764 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIMUS HEALTH CARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRIDGES PRIMARY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963260 | ||||||||
| FaxNumber: | 2036833620 | ||||||||
| Practice Location | |||||||||
| Address1: | 949 BRIDGEPORT AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064603142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038786365 | ||||||||
| FaxNumber: | 2036833615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2015 | ||||||||
| LastUpdateDate: | 05/27/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SPINELLI | ||||||||
| AuthorizedOfficialFirstName: | LUDWIG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2036963260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0748 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004234788 | 05 | CT | MEDICAID | C00383 | 01 | CT | MEDICARE PART B C00383 | OTHER |