MEDICARE: OPTION 1 NUTRITION SOLUTIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609954965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTION 1 NUTRITION SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	PO BOX 841042
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-1042
Country	:	US
Telephone Number	:	480-883-1188
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 OSUNA RD NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4426
Country	:	US
Telephone Number	:	480-883-1188
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT CEO
Name	:	JAMES LLOYD WILEY
Credential	:
Telephone Number	:	480-883-1188

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	10/09/2007

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Directions to “OPTION 1 NUTRITION SOLUTIONS LLC ” Practice Location

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