=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912715244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMAL HEALTH AND WELLNESS CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2024
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5975 KENTSHIRE DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-902-2655
-----------------------------------------------------
Fax | 937-468-4770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5975 KENTSHIRE DR
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45440-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-902-2655
-----------------------------------------------------
Fax | 937-468-4770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ESTHER BASSAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-902-2655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------