Healthcare Provider Details

I. General information

NPI: 1962160622
Provider Name (Legal Business Name): OPTIMAL HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11140 LYNWOOD PALM WAY
PALM BEACH GARDENS FL
33412-2470
US

IV. Provider business mailing address

6 MONTROSE DR
COMMACK NY
11725-1313
US

V. Phone/Fax

Practice location:
  • Phone: 631-300-6320
  • Fax: 954-208-0066
Mailing address:
  • Phone: 631-300-6320
  • Fax: 954-208-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELINE SAMANTHA DEMARCO
Title or Position: OWNER/FUNCTIONAL MED. SPECIALIST
Credential: PHARMD
Phone: 631-300-6320