Healthcare Provider Details

I. General information

NPI: 1326464272
Provider Name (Legal Business Name): OPTIMAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 BALTIMORE BLVD SUITE C
WESTMINSTER MD
21157-7146
US

IV. Provider business mailing address

1812 BALTIMORE BLVD SUITE C
WESTMINSTER MD
21157-7146
US

V. Phone/Fax

Practice location:
  • Phone: 410-861-5256
  • Fax: 410-861-5258
Mailing address:
  • Phone: 410-861-5256
  • Fax: 410-861-5258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberR084575
License Number StateMD

VIII. Authorized Official

Name: LAURA A RUBY
Title or Position: OWNER
Credential: CRNP
Phone: 410-861-5256