1922404151 NPI number — OPTIMIZED LIVING INSTITUTE

Table of content: (NPI 1922404151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922404151 NPI number — OPTIMIZED LIVING INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMIZED LIVING INSTITUTE
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:
OPTIMIZED LIVING INSTITUTE
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:
1922404151
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4700 MILLWOOD DR. #77559
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70879-7559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-339-9911
Provider Business Mailing Address Fax Number:
225-308-9225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8775 JEFFERSON HIGHWAY
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-339-9911
Provider Business Practice Location Address Fax Number:
225-308-9225
Provider Enumeration Date:
11/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BRUNER
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
225-339-9911

Provider Taxonomy Codes

  • Taxonomy code: 111NN1001X , with the licence number:  12675 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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