Healthcare Provider Details

I. General information

NPI: 1205598414
Provider Name (Legal Business Name): OLIVE BRANCH NUTRITION THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/06/2021
Certification Date: 10/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MESSER ST # 4
PROVIDENCE RI
02909-2006
US

IV. Provider business mailing address

20 MESSER ST # 4
PROVIDENCE RI
02909-2006
US

V. Phone/Fax

Practice location:
  • Phone: 508-688-0456
  • Fax:
Mailing address:
  • Phone: 508-688-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAILA SHANAA
Title or Position: OWNER
Credential: RDN
Phone: 508-688-0456