Provider Demographics
NPI:1174520084
Name:OPTIMAE LIFESERVICES, INC,
Entity type:Organization
Organization Name:OPTIMAE LIFESERVICES, INC,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MCSTOCKARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-472-1684
Mailing Address - Street 1:301 W BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-3242
Mailing Address - Country:US
Mailing Address - Phone:641-472-1684
Mailing Address - Fax:641-472-4609
Practice Address - Street 1:301 W BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-3242
Practice Address - Country:US
Practice Address - Phone:641-472-5771
Practice Address - Fax:641-472-1817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA038161041C0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0272021Medicaid
IA58181OtherBCBS
IA70006Medicare ID - Type UnspecifiedGROUP BILLING