Provider Demographics
NPI:1962160622
Name:OPTIMAL HEALTH & WELLNESS LLC
Entity type:Organization
Organization Name:OPTIMAL HEALTH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FUNCTIONAL MED. SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:SAMANTHA
Authorized Official - Last Name:DEMARCO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:631-300-6320
Mailing Address - Street 1:6 MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1313
Mailing Address - Country:US
Mailing Address - Phone:631-300-6320
Mailing Address - Fax:954-208-0066
Practice Address - Street 1:11140 LYNWOOD PALM WAY
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33412-2470
Practice Address - Country:US
Practice Address - Phone:631-300-6320
Practice Address - Fax:954-208-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No335G00000XSuppliersMedical Foods Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL21000465958OtherARTICLES OF ORGANIZATION FOR LLC