1780868059 NPI number — OPTION 1 NUTRITION SOLUTIONS, CA, INC

Table of content: (NPI 1780868059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780868059 NPI number — OPTION 1 NUTRITION SOLUTIONS, CA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTION 1 NUTRITION SOLUTIONS, CA, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OPTION 1 HEALTHCARE SOLUTIONS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780868059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2460 EAST GERMANN ROAD
Provider Second Line Business Mailing Address:
SUITE 18
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-883-1188
Provider Business Mailing Address Fax Number:
480-883-1193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3065 RESEARCH DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-233-7332
Provider Business Practice Location Address Fax Number:
510-758-9088
Provider Enumeration Date:
12/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHARLESWORTH
Authorized Official First Name:
ALLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
866-883-1188

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1780868059 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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