Basic Information
| Provider Information | |||||||||
| NPI: | 1548347156 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTION 1 NUTRITION SOLUTIONS LLC | ||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE MEDICAL SOLUTIONS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2460 EAST GERMANN ROAD | ||||||||
| Address2: | SUITE 18 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808831188 | ||||||||
| FaxNumber: | 4808831193 | ||||||||
| Practice Location | |||||||||
| Address1: | 4990 NOME ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802392735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7205298323 | ||||||||
| FaxNumber: | 7205295748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 61224375 | 05 | CO | MEDICAID |