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General NPI Number Information
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NPI Number | 1023408655
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Entity Type | Organization
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Legal Business Name | OPTIMUM WELLNESS & SPINE REHABILITATION CENTER
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Dates
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Enumeration Date | 02/04/2015
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Last Update Date | 02/04/2015
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Provider Practice Location Address
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Address Line | 1805 S 25TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34947-4752
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Country | US
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Telephone | 772-448-8365
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Fax | 772-448-8341
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Provider Business Mailing Address
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Address Line | 1805 S. 25TH STREET ST. B
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City | FORT PIERCE
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State | FL
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Zip | 34947
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Country | US
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Telephone | 772-448-8365
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Fax | 772-448-8341
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Authorized Official
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Title or Position | OWNER
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Name | HERMIONE B JOURDAN
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Credential | D.C
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Telephone | 561-512-5198
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH9971
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License Number State | FL
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