Provider Demographics
NPI:1386033488
Name:OPTIMAL NUTRITION
Entity Type:Organization
Organization Name:OPTIMAL NUTRITION
Other - Org Name:OPTIMAL NUTRITION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIETITIAN NUTRITIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:REUTOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-706-2696
Mailing Address - Street 1:731 KALUGIN CT
Mailing Address - Street 2:
Mailing Address - City:MOLALLA
Mailing Address - State:OR
Mailing Address - Zip Code:97038-8815
Mailing Address - Country:US
Mailing Address - Phone:503-706-2696
Mailing Address - Fax:866-344-7774
Practice Address - Street 1:731 KALUGIN CT
Practice Address - Street 2:
Practice Address - City:MOLALLA
Practice Address - State:OR
Practice Address - Zip Code:97038-8815
Practice Address - Country:US
Practice Address - Phone:503-706-2696
Practice Address - Fax:866-344-7774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR107678997133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty