Provider Demographics
NPI:1780007674
Name:OPTI HEALTH PLLC
Entity type:Organization
Organization Name:OPTI HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXIMINO
Authorized Official - Middle Name:ALFREDO
Authorized Official - Last Name:MEJIA
Authorized Official - Suffix:
Authorized Official - Credentials:DRPH, RD
Authorized Official - Phone:269-351-6007
Mailing Address - Street 1:6521 E MAIN ST
Mailing Address - Street 2:P.O. BOX 37
Mailing Address - City:EAU CLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49111-5129
Mailing Address - Country:US
Mailing Address - Phone:269-351-6007
Mailing Address - Fax:
Practice Address - Street 1:6521 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49111-5129
Practice Address - Country:US
Practice Address - Phone:269-351-6007
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
IL164.004618133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty