Provider Demographics
NPI:1699012435
Name:OPTIMA WEIGHT & WELLNESS, LLC
Entity Type:Organization
Organization Name:OPTIMA WEIGHT & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS/HR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-429-5148
Mailing Address - Street 1:1489 E 15TH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5054
Mailing Address - Country:US
Mailing Address - Phone:405-715-1919
Mailing Address - Fax:405-212-5043
Practice Address - Street 1:1489 E 15TH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5054
Practice Address - Country:US
Practice Address - Phone:405-715-1919
Practice Address - Fax:405-212-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care