Basic Information
| Provider Information | |||||||||
| NPI: | 1992871875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTIMUS HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 471 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066082409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035763885 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Practice Location | |||||||||
| Address1: | 471 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066082409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035763885 | ||||||||
| FaxNumber: | 2033320376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 08/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | SPINELLI | ||||||||
| AuthorizedOfficialFirstName: | LUDWIG | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2036963260 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 00073 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | C00383 | 01 | CT | MEDICARE PART B | OTHER | 004235926 | 05 | CT | MEDICAID |