Provider Demographics
NPI:1619390671
Name:OPTIMUM HEALTH AND NUTRITION, INC
Entity Type:Organization
Organization Name:OPTIMUM HEALTH AND NUTRITION, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN, LDN
Authorized Official - Phone:708-527-0772
Mailing Address - Street 1:8805 S 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:HICKORY HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60457-1444
Mailing Address - Country:US
Mailing Address - Phone:708-527-0772
Mailing Address - Fax:
Practice Address - Street 1:8805 S 82ND AVE
Practice Address - Street 2:
Practice Address - City:HICKORY HILLS
Practice Address - State:IL
Practice Address - Zip Code:60457-1444
Practice Address - Country:US
Practice Address - Phone:708-527-0772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005838302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619308608OtherMEDICARE NPI TYPE I LISTED BELOW
IL0670OtherCNA
IL164.005838OtherLICENSED DIETITIAN NUTRITIONIST LICENSE NUMBER