Provider Demographics
NPI:1366733172
Name:OPTIMUS PHYSICAL THERAPY AND ORTHOSPORT SPECIALISTS PLLC
Entity type:Organization
Organization Name:OPTIMUS PHYSICAL THERAPY AND ORTHOSPORT SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNIX
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:432-934-5609
Mailing Address - Street 1:2760 N GRANDVIEW AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-6953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2760 N GRANDVIEW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-6953
Practice Address - Country:US
Practice Address - Phone:432-934-5609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-27
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty