Provider Demographics
NPI:1306277967
Name:OPTIMAL WELLNESS MEDICAL GROUP, INC
Entity type:Organization
Organization Name:OPTIMAL WELLNESS MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:626-551-5155
Mailing Address - Street 1:670 MONTEREY PASS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-2436
Mailing Address - Country:US
Mailing Address - Phone:616-551-5155
Mailing Address - Fax:626-551-5156
Practice Address - Street 1:670 MONTEREY PASS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-2436
Practice Address - Country:US
Practice Address - Phone:616-551-5155
Practice Address - Fax:626-551-5156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC33051111N00000X
CAAC16000171100000X
CAND385175F00000X
CA225100000X
CAA40257208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty