Provider Demographics
NPI:1205598414
Name:OLIVE BRANCH NUTRITION THERAPY LLC
Entity type:Organization
Organization Name:OLIVE BRANCH NUTRITION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAILA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANAA
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:508-688-0456
Mailing Address - Street 1:20 MESSER ST # 4
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-2006
Mailing Address - Country:US
Mailing Address - Phone:508-688-0456
Mailing Address - Fax:
Practice Address - Street 1:20 MESSER ST # 4
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-2006
Practice Address - Country:US
Practice Address - Phone:508-688-0456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service