Provider Demographics
NPI:1952758906
Name:TRACEY ONEILL INC
Entity Type:Organization
Organization Name:TRACEY ONEILL INC
Other - Org Name:LIVE WELL WITH FOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ONEILL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, FMCHC CANDIDATE
Authorized Official - Phone:386-846-3355
Mailing Address - Street 1:6127 WHITE TIP RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-3115
Mailing Address - Country:US
Mailing Address - Phone:386-846-3355
Mailing Address - Fax:
Practice Address - Street 1:6127 WHITE TIP RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-3115
Practice Address - Country:US
Practice Address - Phone:386-846-3355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003201133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty