Provider Demographics
NPI:1174593222
Name:OPTIMA PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:OPTIMA PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GANIYU
Authorized Official - Middle Name:ABIOLA
Authorized Official - Last Name:BELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:770-994-4335
Mailing Address - Street 1:808 COMMERCE BLVD
Mailing Address - Street 2:SUITE C2
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-7192
Mailing Address - Country:US
Mailing Address - Phone:770-994-4335
Mailing Address - Fax:770-994-1559
Practice Address - Street 1:808 COMMERCE BLVD
Practice Address - Street 2:SUITE C2
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-7192
Practice Address - Country:US
Practice Address - Phone:770-994-4335
Practice Address - Fax:770-994-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0061052251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA227393067AMedicaid
GA227393067AMedicaid