Provider Demographics
NPI:1972556934
Name:AMERICAN OPTIMAL HEALTH
Entity type:Organization
Organization Name:AMERICAN OPTIMAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATION OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-323-1481
Mailing Address - Street 1:601 RAMSEY STREET
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-4705
Mailing Address - Country:US
Mailing Address - Phone:910-323-1481
Mailing Address - Fax:910-323-1282
Practice Address - Street 1:726 RAMSEY ST
Practice Address - Street 2:SUITE 3
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-4705
Practice Address - Country:US
Practice Address - Phone:910-486-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0151AOtherBCBS GRP NUMBER
NC890151AMedicaid
NC0151AOtherBCBS GRP NUMBER
NC0151AOtherBCBS GRP NUMBER