Healthcare Provider Details

I. General information

NPI: 1861540239
Provider Name (Legal Business Name): OPTIMUM WELLNESS AND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 S STATE ROUTE 157
GLEN CARBON IL
62034-1042
US

IV. Provider business mailing address

3407 S STATE ROUTE 157
GLEN CARBON IL
62034-1042
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-3610
  • Fax:
Mailing address:
  • Phone: 618-288-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.005639
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-006607
License Number StateIL

VIII. Authorized Official

Name: DR. RICHARD C COY
Title or Position: PRESIDENT
Credential: DC
Phone: 618-288-3610