Healthcare Provider Details

I. General information

NPI: 1598306409
Provider Name (Legal Business Name): LIFEOPTIMIZED INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 HG TRUEMAN RD STE 2300-710
SOLOMONS MD
20688-3151
US

IV. Provider business mailing address

16 INGATE TER
ARBUTUS MD
21227-3849
US

V. Phone/Fax

Practice location:
  • Phone: 443-386-6561
  • Fax:
Mailing address:
  • Phone: 410-340-6042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name: IRA R BURCHAM
Title or Position: CFO
Credential:
Phone: 410-340-6042