Organization
OPTIMUM HEALTH AND NUTRITION, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RAQUEL LOPEZ RDN, LDN (PRESIDENT/ REGISTERED DIETITIAN)
(708) 527-0772
Entity
Organization
Contact information
Practice address
8805 S 82ND AVE, HICKORY HILLS, IL 60457-1444
(708) 527-0772
Mailing address
8805 S 82ND AVE, HICKORY HILLS, IL 60457-1444
(708) 527-0772
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
164.005838
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0670
CNA
IL
01
—
1619308608
MEDICARE NPI TYPE I LISTED BELOW
IL
01
—
164.005838
LICENSED DIETITIAN NUTRITIONIST LICENSE NUMBER
IL
Enumeration date
01/28/2014
Last updated
01/28/2014
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