1720060601 NPI number — OMNI HOME HEALTH DISTRICT 4, LLC

Table of content: (NPI 1720060601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720060601 NPI number — OMNI HOME HEALTH DISTRICT 4, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI HOME HEALTH DISTRICT 4, LLC
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:
6
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:
1720060601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
510 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37115-5033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-712-2250
Provider Business Mailing Address Fax Number:
615-577-0081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2651 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-4519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-389-7385
Provider Business Practice Location Address Fax Number:
904-389-7359
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCFADDIN
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF LICENSING & ACCREDITATI
Authorized Official Telephone Number:
615-712-2250

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  299991765 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004233000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 114886400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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