Provider Demographics
NPI:1962620005
Name:OPTIMUM CLINICAL CARE, PLLC
Entity type:Organization
Organization Name:OPTIMUM CLINICAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:THERTULIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:704-333-1555
Mailing Address - Street 1:PO BOX 220504
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-0504
Mailing Address - Country:US
Mailing Address - Phone:704-333-1555
Mailing Address - Fax:704-333-1553
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:SUITE 140
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-333-1555
Practice Address - Fax:704-333-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center