Provider Demographics
NPI:1114758208
Name:OPTIMAL SELF CARE PHYSICAL THERAPY
Entity type:Organization
Organization Name:OPTIMAL SELF CARE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER,PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:WINTER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:815-325-5815
Mailing Address - Street 1:67 E YALE LOOP
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3336
Mailing Address - Country:US
Mailing Address - Phone:815-325-5815
Mailing Address - Fax:
Practice Address - Street 1:67 E YALE LOOP
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3336
Practice Address - Country:US
Practice Address - Phone:815-325-5815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty