MEDICARE: OPTIMAL HEALTH CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1750971404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL HEALTH CLINIC INC

Provider Business Mailing Address
First Line	:	28315 S TAMIAMI TRL STE 101
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-3217
Country	:	US
Telephone Number	:	239-947-1177
Fax Number	:

Provider Business Practice Location Address
First Line	:	28315 S TAMIAMI TRL STE 101
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-3217
Country	:	US
Telephone Number	:	239-947-1177
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GARY GENDRON
Credential	:	DC
Telephone Number	:	235-947-1177

Provider Enumeration Date	:	01/26/2021
Last Update Date	:	01/26/2021

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