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General NPI Number Information
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NPI Number | 1619390671
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Entity Type | Organization
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Legal Business Name | OPTIMUM HEALTH AND NUTRITION, INC
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Dates
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Enumeration Date | 01/28/2014
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Last Update Date | 01/28/2014
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Provider Practice Location Address
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Address Line | 8805 S 82ND AVE
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City | HICKORY HILLS
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State | IL
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Zip | 60457-1444
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Country | US
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Telephone | 708-527-0772
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Fax |
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Provider Business Mailing Address
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Address Line | 8805 S 82ND AVE
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City | HICKORY HILLS
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State | IL
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Zip | 60457-1444
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Country | US
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Telephone | 708-527-0772
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ REGISTERED DIETITIAN
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Name | RAQUEL LOPEZ
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Credential | RDN, LDN
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Telephone | 708-527-0772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 164.005838
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License Number State | IL
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