Healthcare Provider Details

I. General information

NPI: 1134619208
Provider Name (Legal Business Name): OMEGA HEALTH AND NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2624 ATLANTIC BLVD
JACKSONVILLE FL
32207-3609
US

IV. Provider business mailing address

700 N INDIGO TER
SAINT JOHNS FL
32259-4465
US

V. Phone/Fax

Practice location:
  • Phone: 904-413-3360
  • Fax:
Mailing address:
  • Phone: 904-413-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MONICA CAROLINA MEDINA-DOBBS
Title or Position: DIETICIAN-NUTRITIONIST
Credential: LDN
Phone: 904-413-3360