Provider Demographics
NPI:1699326298
Name:OPTIMUM PERFORMANCE THERAPEUTIC MASSAGE & BODYWORK LLC
Entity type:Organization
Organization Name:OPTIMUM PERFORMANCE THERAPEUTIC MASSAGE & BODYWORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GASSNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CLT
Authorized Official - Phone:203-707-1013
Mailing Address - Street 1:325 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-4230
Mailing Address - Country:US
Mailing Address - Phone:203-707-1013
Mailing Address - Fax:203-405-1798
Practice Address - Street 1:325 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4230
Practice Address - Country:US
Practice Address - Phone:203-707-1013
Practice Address - Fax:203-405-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT009561OtherSTATE LICENSE