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General NPI Number Information
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NPI Number | 1538794250
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Entity Type | Organization
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Legal Business Name | LIFEOPTIMIZED - BENNERMEDICAL INC
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Dates
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Enumeration Date | 03/04/2020
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Last Update Date | 10/28/2020
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Provider Practice Location Address
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Address Line | 14090 HG TRUEMAN RD STE 2300
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City | SOLOMONS
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State | MD
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Zip | 20688-3151
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Country | US
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Telephone | 443-386-6561
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Fax |
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Provider Business Mailing Address
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Address Line | 16 INGATE TER
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City | ARBUTUS
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State | MD
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Zip | 21227-3849
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Country | US
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Telephone | 443-386-6561
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | JAMES NICHOLS
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Credential |
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Telephone | 443-386-6561
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133VN1201X
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Taxonomy Name | Obesity and Weight Management Nutrition Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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