Healthcare Provider Details

I. General information

NPI: 1982837647
Provider Name (Legal Business Name): OPTIMAL WELLNESS & BODY SCULPTING INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 WALNUT ST LL30
PHILADELPHIA PA
19106-3323
US

IV. Provider business mailing address

915 BAINBRIDGE ST #102
PHILADELPHIA PA
19147-1947
US

V. Phone/Fax

Practice location:
  • Phone: 215-238-5751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY D SHABLIN
Title or Position: PRESIDENT
Credential:
Phone: 215-238-5751