Provider Demographics
NPI:1629725312
Name:TRACEY L O'NEILL LLC
Entity Type:Organization
Organization Name:TRACEY L O'NEILL LLC
Other - Org Name:LONGEVITY FUNCTIONAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:LDN, CNS
Authorized Official - Phone:904-535-6901
Mailing Address - Street 1:500 CANAL RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4300
Mailing Address - Country:US
Mailing Address - Phone:904-535-6901
Mailing Address - Fax:
Practice Address - Street 1:500 CANAL RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4300
Practice Address - Country:US
Practice Address - Phone:904-535-6901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty