Provider Demographics
NPI:1609954965
Name:OPTION 1 NUTRITION SOLUTIONS LLC
Entity Type:Organization
Organization Name:OPTION 1 NUTRITION SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-883-1188
Mailing Address - Street 1:PO BOX 841042
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1042
Mailing Address - Country:US
Mailing Address - Phone:480-883-1188
Mailing Address - Fax:
Practice Address - Street 1:3600 OSUNA RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4426
Practice Address - Country:US
Practice Address - Phone:480-883-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41970721Medicaid