Provider Demographics
NPI:1386475465
Name:OPTIMAL LIFE INTEGRATIVE HEALTH CLINIC LLC
Entity type:Organization
Organization Name:OPTIMAL LIFE INTEGRATIVE HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:YUSUPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUKUREH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:347-849-1576
Mailing Address - Street 1:105 W 125TH ST FRNT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4444
Mailing Address - Country:US
Mailing Address - Phone:347-872-9006
Mailing Address - Fax:
Practice Address - Street 1:105 W 125TH ST FRNT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4444
Practice Address - Country:US
Practice Address - Phone:347-872-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty