Provider Demographics
NPI:1154081909
Name:OPTIMUM WELLNESS CENTER LLC.
Entity type:Organization
Organization Name:OPTIMUM WELLNESS CENTER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:XAVIER
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-627-3386
Mailing Address - Street 1:3455 WILKENS AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5214
Mailing Address - Country:US
Mailing Address - Phone:410-627-3386
Mailing Address - Fax:410-646-0747
Practice Address - Street 1:3455 WILKENS AVE STE 301
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5214
Practice Address - Country:US
Practice Address - Phone:410-627-3386
Practice Address - Fax:410-646-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health