Provider Demographics
NPI:1396199238
Name:OPTIMUM LIFE WELLNESS LLC
Entity Type:Organization
Organization Name:OPTIMUM LIFE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:BAKARI
Authorized Official - Middle Name:E
Authorized Official - Last Name:VICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-423-7215
Mailing Address - Street 1:2092 CAVANAUGH AVE SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2704
Mailing Address - Country:US
Mailing Address - Phone:404-423-7215
Mailing Address - Fax:678-515-3408
Practice Address - Street 1:2801 BUFORD HWY NE STE 501
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2137
Practice Address - Country:US
Practice Address - Phone:404-423-7215
Practice Address - Fax:678-515-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA066914261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)