Provider Demographics
NPI:1073086203
Name:OPTIMAL NUTRITION LLC
Entity Type:Organization
Organization Name:OPTIMAL NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RABITA
Authorized Official - Last Name:SHETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-916-2486
Mailing Address - Street 1:65 KELSEY LN
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5040
Mailing Address - Country:US
Mailing Address - Phone:860-916-2486
Mailing Address - Fax:
Practice Address - Street 1:65 KELSEY LN
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-5040
Practice Address - Country:US
Practice Address - Phone:860-916-2486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service