Provider Demographics
NPI:1770014656
Name:CT OPTIMAL WELLNESS, LLC
Entity Type:Organization
Organization Name:CT OPTIMAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-215-9179
Mailing Address - Street 1:124 W 60TH STREET
Mailing Address - Street 2:SUITE 35D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 PEARL ST
Practice Address - Street 2:12 FLOOR
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06103
Practice Address - Country:US
Practice Address - Phone:860-725-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT52588261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care