Provider Demographics
NPI:1922404151
Name:OPTIMIZED LIVING INSTITUTE
Entity Type:Organization
Organization Name:OPTIMIZED LIVING INSTITUTE
Other - Org Name:OPTIMIZED LIVING INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BRUNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-339-9911
Mailing Address - Street 1:4700 MILLWOOD DR. #77559
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70879-7559
Mailing Address - Country:US
Mailing Address - Phone:225-339-9911
Mailing Address - Fax:225-308-9225
Practice Address - Street 1:8775 JEFFERSON HIGHWAY
Practice Address - Street 2:SUITE E
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-339-9911
Practice Address - Fax:225-308-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12675111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty