Provider Demographics
NPI:1316317381
Name:OPTIMUM POTENTIAL COMMUNITY SERVICES
Entity type:Organization
Organization Name:OPTIMUM POTENTIAL COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TARGETED CASE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:321-333-9197
Mailing Address - Street 1:120 BROADWAY STE 306
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5706
Mailing Address - Country:US
Mailing Address - Phone:407-201-6577
Mailing Address - Fax:
Practice Address - Street 1:120 BROADWAY
Practice Address - Street 2:SUITE 306
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5703
Practice Address - Country:US
Practice Address - Phone:407-201-6577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health