Provider Demographics
NPI:1104899509
Name:OPTIMUM KIDS LTD
Entity type:Organization
Organization Name:OPTIMUM KIDS LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSYCA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-600-7921
Mailing Address - Street 1:1240 E BUSINESS 83 STE A
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-9600
Mailing Address - Country:US
Mailing Address - Phone:956-600-7921
Mailing Address - Fax:956-600-7923
Practice Address - Street 1:1240 E US BUSINESS 83
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572
Practice Address - Country:US
Practice Address - Phone:956-664-9955
Practice Address - Fax:956-664-9957
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIMUM KIDS LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-08
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0401X
TX654180000261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1631301Medicaid
TX1631301Medicaid