Provider Demographics
NPI:1760034292
Name:OPTIMALLY NOURISHED LLC
Entity Type:Organization
Organization Name:OPTIMALLY NOURISHED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:224-436-2606
Mailing Address - Street 1:48 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1063
Mailing Address - Country:US
Mailing Address - Phone:224-436-2606
Mailing Address - Fax:
Practice Address - Street 1:303 BELMONT AVE STE 2
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1103
Practice Address - Country:US
Practice Address - Phone:973-751-8411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center