Provider Demographics
NPI:1457794034
Name:OPTIMAL FUNCTION MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:OPTIMAL FUNCTION MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DELUCA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-899-5014
Mailing Address - Street 1:1022 JEFFERY ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4183
Mailing Address - Country:US
Mailing Address - Phone:561-899-5014
Mailing Address - Fax:
Practice Address - Street 1:600 SANDTREE DR
Practice Address - Street 2:SUITE 206B
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1597
Practice Address - Country:US
Practice Address - Phone:561-899-5014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102199261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty