Healthcare Provider Details

I. General information

NPI: 1386033488
Provider Name (Legal Business Name): OPTIMAL NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 KALUGIN CT
MOLALLA OR
97038-8815
US

IV. Provider business mailing address

731 KALUGIN CT
MOLALLA OR
97038-8815
US

V. Phone/Fax

Practice location:
  • Phone: 503-706-2696
  • Fax: 866-344-7774
Mailing address:
  • Phone: 503-706-2696
  • Fax: 866-344-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number107678997
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number107678997
License Number StateOR

VIII. Authorized Official

Name: ANNA K REUTOV
Title or Position: DIETITIAN NUTRITIONAL THERAPIST
Credential:
Phone: 503-706-2696