MEDICARE: OPTIMUM NUTRITION CENTER, INC

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	133N00000X	Nutritionist		GA

General Provider Information

NPI Number	:	1770740201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM NUTRITION CENTER, INC

Provider Business Mailing Address
First Line	:	4923 ARMOUR RD STE 200
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-5038
Country	:	US
Telephone Number	:	800-351-6659
Fax Number	:	706-322-1804

Provider Business Practice Location Address
First Line	:	4923 ARMOUR RD STE 200
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31904-5038
Country	:	US
Telephone Number	:	800-351-6659
Fax Number	:	706-322-1804

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. MICHAEL EUGENE SECKINGER SR.
Credential	:	C.N., N.D.
Telephone Number	:	18003516659

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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