Provider Demographics
NPI:1285935882
Name:CENTER FOR OPTIMAL LIFE
Entity type:Organization
Organization Name:CENTER FOR OPTIMAL LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:202-247-1137
Mailing Address - Street 1:523 BOCA CHICA CIR
Mailing Address - Street 2:101
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4891
Mailing Address - Country:US
Mailing Address - Phone:202-247-1137
Mailing Address - Fax:
Practice Address - Street 1:523 BOCA CHICA CIR
Practice Address - Street 2:101
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4891
Practice Address - Country:US
Practice Address - Phone:202-247-1137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8137305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service