Healthcare Provider Details

I. General information

NPI: 1467250415
Provider Name (Legal Business Name): OPTIMAL ROYAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S MILL AVE STE 223
TEMPE AZ
85282-2138
US

IV. Provider business mailing address

2220 W DORA ST APT 203
MESA AZ
85201-6045
US

V. Phone/Fax

Practice location:
  • Phone: 813-310-3569
  • Fax:
Mailing address:
  • Phone: 813-310-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN LEWIS IV
Title or Position: OWNER
Credential: LAC
Phone: 813-310-3569