1194893842 NPI number — OMEGA INDEPENDENT LIVING SERVICES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194893842 NPI number — OMEGA INDEPENDENT LIVING SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMEGA INDEPENDENT LIVING SERVICES, 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:
Provider Other Organization Name Type Code:
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:
1194893842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3029 STONY BROOK DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27604-3790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-255-3268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3029 STONY BROOK DR
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27604-3790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-255-3268
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRANTHAM
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
919-255-3268

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6005361 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603739 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6604281 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300455G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603869 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6604054 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300455B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6604021 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603391 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603948 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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