Basic Information
| Provider Information | |||||||||
| NPI: | 1609954965 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTION 1 NUTRITION SOLUTIONS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841042 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808831188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 OSUNA RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808831188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | WILEY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | LLOYD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808831188 | ||||||||
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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 | 41970721 | 05 | NM | MEDICAID |