Provider Demographics
NPI:1063916195
Name:OPTIMAL WELLNESS LLC
Entity type:Organization
Organization Name:OPTIMAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SREEDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:YERRAPRAGADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-716-1200
Mailing Address - Street 1:745 OLIVE STREET
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104
Mailing Address - Country:US
Mailing Address - Phone:318-716-1200
Mailing Address - Fax:318-562-3330
Practice Address - Street 1:745 OLIVE STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-716-1200
Practice Address - Fax:318-562-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty