Basic Information
| Provider Information | |||||||||
| NPI: | 1164798138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTIMUS HEALTH CARE INC | ||||||||
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| OtherOrganizationName: | WOODLAND HEALTH AND WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 982 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066081913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036963260 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 8 WOODLAND PL | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069026939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033484444 | ||||||||
| FaxNumber: | 2033489900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | SPINELLI | ||||||||
| AuthorizedOfficialFirstName: | LUDWIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2036963260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0629 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004234788 | 05 | CT | MEDICAID |