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General NPI Number Information
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NPI Number | 1770014656
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Entity Type | Organization
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Legal Business Name | CT OPTIMAL WELLNESS, LLC
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 03/23/2017
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Provider Practice Location Address
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Address Line | 100 PEARL ST 12 FLOOR
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City | HARTFORD
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State | CT
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Zip | 06103
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Country | US
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Telephone | 860-725-0025
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Fax |
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Provider Business Mailing Address
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Address Line | 124 W 60TH STREET SUITE 35D
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City | NEW YORK
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State | NY
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Zip | 10023
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JENNIFER SIRCH
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Credential |
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Telephone | 203-215-9179
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 52588
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License Number State | CT
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