Provider Demographics
NPI:1447756804
Name:OPTIMUM HEALTH RESTORATION AND ANTI-AGING - TOLEDO, LLC
Entity Type:Organization
Organization Name:OPTIMUM HEALTH RESTORATION AND ANTI-AGING - TOLEDO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KORTH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:614-539-4128
Mailing Address - Street 1:3699 GARDEN COURT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123
Mailing Address - Country:US
Mailing Address - Phone:614-539-4128
Mailing Address - Fax:888-631-0223
Practice Address - Street 1:4041 SYLVANIA AVENUE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623
Practice Address - Country:US
Practice Address - Phone:614-539-4128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty