Provider Demographics
NPI:1750971404
Name:OPTIMAL HEALTH CLINIC INC
Entity type:Organization
Organization Name:OPTIMAL HEALTH CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GENDRON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:235-947-1177
Mailing Address - Street 1:28315 S TAMIAMI TRL STE 101
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-3217
Mailing Address - Country:US
Mailing Address - Phone:239-947-1177
Mailing Address - Fax:
Practice Address - Street 1:28315 S TAMIAMI TRL STE 101
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-3217
Practice Address - Country:US
Practice Address - Phone:239-947-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty