Healthcare Provider Details

I. General information

NPI: 1952088254
Provider Name (Legal Business Name): OPTIMAL HEALTH CLINICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 RING RD STE 100
ELIZABETHTOWN KY
42701-7941
US

IV. Provider business mailing address

2415 RING RD STE 100
ELIZABETHTOWN KY
42701-7941
US

V. Phone/Fax

Practice location:
  • Phone: 270-765-2157
  • Fax:
Mailing address:
  • Phone: 270-765-2157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENT WILLIAMS
Title or Position: DIRECTOR
Credential:
Phone: 270-765-2157