Basic Information
| Provider Information | |||||||||
| NPI: | 1659836633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTIMUM THERAPY AND WELLNESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6349 FARTHING DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809067504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132696120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2020 N ACADEMY BLVD | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809091567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132696120 | ||||||||
| FaxNumber: | 7192192321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | SLIVKA | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 9132696120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 29220025 | 05 | CO | MEDICAID |