1861537995 NPI number — OMNI PHYSICAL & AQUATIC THERAPY CENTER, INC

Table of content: (NPI 1861537995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861537995 NPI number — OMNI PHYSICAL & AQUATIC THERAPY CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI PHYSICAL & AQUATIC THERAPY CENTER, 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:
OMNI MEDICAL
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:
1861537995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 RESEARCH PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALLINGFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06492-1929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-294-1998
Provider Business Mailing Address Fax Number:
203-294-1189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 RESEARCH PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-294-1998
Provider Business Practice Location Address Fax Number:
203-294-1189
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAHONEY-RANDALL
Authorized Official First Name:
TRISHA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
203-877-0112

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111NR0400X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251G0304X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6404254 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: A667399 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004173184 . This is a "BLUE CARE FAMILY PLAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 712712 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004173184 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004255271 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0V1691 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 183158 . This is a "FIRST CHOICE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 552470 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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