Provider Demographics
NPI:1992900823
Name:OPTIMUM CARE HP
Entity type:Organization
Organization Name:OPTIMUM CARE HP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-890-5720
Mailing Address - Street 1:1616 E MAIN ST
Mailing Address - Street 2:208 E
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-9071
Mailing Address - Country:US
Mailing Address - Phone:480-890-5720
Mailing Address - Fax:
Practice Address - Street 1:1616 E MAIN ST
Practice Address - Street 2:208 E
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-9071
Practice Address - Country:US
Practice Address - Phone:480-890-5720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ927585OtherAHCCCS ID NUMBER