Healthcare Provider Details

I. General information

NPI: 1467024554
Provider Name (Legal Business Name): OPTIMALLY VIBRANT HEALTH & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

834 SWEET BIRCH DR
MIDDLETOWN DE
19709-7873
US

IV. Provider business mailing address

364 E MAIN ST STE 1508
MIDDLETOWN DE
19709-1482
US

V. Phone/Fax

Practice location:
  • Phone: 302-376-6901
  • Fax:
Mailing address:
  • Phone: 302-314-2950
  • Fax: 302-378-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MALAIKA OMOWALE-MCQUILLER
Title or Position: OWNER
Credential: CNS, LDN
Phone: 302-314-2950