MEDICARE: OPTIMAL WELLNESS REDEFINED, LLC

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	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1932665668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL WELLNESS REDEFINED, LLC

Provider Business Mailing Address
First Line	:	7560 RED BUG LAKE ROAD
Second Line	:	SUITE #1080
City	:	OVIEDO
State	:	FL
Zip	:	32765-6601
Country	:	US
Telephone Number	:	407-901-7704
Fax Number	:	407-288-8582

Provider Business Practice Location Address
First Line	:	2765 REBECCA LN STE D
Second Line	:
City	:	ORANGE CITY
State	:	FL
Zip	:	32763-8326
Country	:	US
Telephone Number	:	407-901-7704
Fax Number	:	407-288-8582

Authorized Official
Title or Position	:	OWNER
Name	:	LARISA SUSAN SCOTT
Credential	:
Telephone Number	:	407-901-7704

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	09/06/2023

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