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General NPI Number Information
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NPI Number | 1912370321
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Entity Type | Organization
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Legal Business Name | OPTIMAL WELLNESS & LONGEVITY INSTITUTE, LLC
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Dates
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Enumeration Date | 11/06/2015
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Last Update Date | 11/06/2015
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Provider Practice Location Address
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Address Line | 875 MILITARY TRL SUITE 105
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City | JUPITER
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State | FL
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Zip | 33458-5700
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Country | US
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Telephone | 561-803-8407
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Fax |
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Provider Business Mailing Address
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Address Line | 875 MILITARY TRL SUITE 105
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City | JUPITER
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State | FL
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Zip | 33458-5700
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Country | US
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Telephone | 561-803-8407
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | HARVEY MONTIJO
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Credential | M.D.
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Telephone | 561-803-8407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | ME 53688
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License Number State | FL
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