Provider Demographics
NPI:1497127260
Name:OPTIMAL WELLNESS OF WEST HARTFORD,LLC
Entity Type:Organization
Organization Name:OPTIMAL WELLNESS OF WEST HARTFORD,LLC
Other - Org Name:MEDI-WEIGHTLOSS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIZA
Authorized Official - Middle Name:F
Authorized Official - Last Name:PETRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-553-2700
Mailing Address - Street 1:1001 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2135
Mailing Address - Country:US
Mailing Address - Phone:860-213-8365
Mailing Address - Fax:
Practice Address - Street 1:1001 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2135
Practice Address - Country:US
Practice Address - Phone:860-213-8365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X207QB0002X
207R00000X207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty