Provider Demographics
NPI:1376352765
Name:OPTIMA MED SPA PLLC
Entity type:Organization
Organization Name:OPTIMA MED SPA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-768-7000
Mailing Address - Street 1:3315 WILLIAMS BLVD SW # 2-112
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-1478
Mailing Address - Country:US
Mailing Address - Phone:319-573-2891
Mailing Address - Fax:
Practice Address - Street 1:2517 NOVAK CT SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-4100
Practice Address - Country:US
Practice Address - Phone:319-573-2891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-31
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight ManagementGroup - Single Specialty