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General NPI Number Information
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NPI Number | 1386033488
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Entity Type | Organization
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Legal Business Name | OPTIMAL NUTRITION
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Dates
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Enumeration Date | 01/13/2015
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 731 KALUGIN CT
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City | MOLALLA
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State | OR
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Zip | 97038-8815
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Country | US
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Telephone | 503-706-2696
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Fax | 866-344-7774
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Provider Business Mailing Address
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Address Line | 731 KALUGIN CT
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City | MOLALLA
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State | OR
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Zip | 97038-8815
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Country | US
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Telephone | 503-706-2696
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Fax | 866-344-7774
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Authorized Official
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Title or Position | DIETITIAN NUTRITIONAL THERAPIST
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Name | ANNA K REUTOV
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Credential |
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Telephone | 503-706-2696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number | 107678997
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 107678997
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License Number State | OR
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