Provider Demographics
NPI:1083856488
Name:OPTIMAL WELLNESS CENTER OF INDIANA, L.L.C.
Entity type:Organization
Organization Name:OPTIMAL WELLNESS CENTER OF INDIANA, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:HUNTER
Authorized Official - Last Name:MONTIETH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-504-0425
Mailing Address - Street 1:4375 GEORGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-2150
Mailing Address - Country:US
Mailing Address - Phone:317-504-0425
Mailing Address - Fax:317-216-7479
Practice Address - Street 1:4375 GEORGETOWN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2150
Practice Address - Country:US
Practice Address - Phone:317-504-0425
Practice Address - Fax:317-216-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002369A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty