Provider Demographics
NPI:1396128377
Name:OPTIMUM HEALTH & FITNESS LLC
Entity type:Organization
Organization Name:OPTIMUM HEALTH & FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIBRIA
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:GOLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-248-0861
Mailing Address - Street 1:566 STATE RT 23
Mailing Address - Street 2:
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444-1420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:566 STATE RT 23
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1420
Practice Address - Country:US
Practice Address - Phone:862-248-0861
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1096687133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty