Provider Demographics
NPI:1871087627
Name:OPT4WELLNESS, LLC
Entity type:Organization
Organization Name:OPT4WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HIMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-580-4059
Mailing Address - Street 1:350 OLD GATE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31820-4777
Mailing Address - Country:US
Mailing Address - Phone:706-580-4059
Mailing Address - Fax:706-566-4377
Practice Address - Street 1:2039 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1459
Practice Address - Country:US
Practice Address - Phone:706-566-5764
Practice Address - Fax:706-566-4377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty