Healthcare Provider Details

I. General information

NPI: 1225100332
Provider Name (Legal Business Name): OPTIMAL BALANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2676 NW PICKETT CT
BEND OR
97701-6807
US

IV. Provider business mailing address

2676 NW PICKETT CT
BEND OR
97701-6807
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-9261
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number653
License Number StateOR

VIII. Authorized Official

Name: LYNNE OLDHAM
Title or Position: OWNER
Credential:
Phone: 541-388-9261