1396780946 NPI number — OMADA, INC.

Table of content: (NPI 1396780946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396780946 NPI number — OMADA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMADA, 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:
OMADA BEHAVIORAL HEALTH SERVICES
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:
1396780946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 DIVISION ST S
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NORTHFIELD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55057-2095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-664-9407
Provider Business Mailing Address Fax Number:
507-664-3862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 DIVISION ST S
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
NORTHFIELD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55057-2095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-664-9407
Provider Business Practice Location Address Fax Number:
507-664-3862
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
B
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
507-664-9407

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  1023523-2-CDT , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 173158 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5045989 . This is a "MEDICA/UBH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 91167 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2H51OM . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 124611 . This is a "MMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1032951 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".




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