MEDICARE: OMNI HOME HEALTHCARE INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency		WI

General Provider Information

NPI Number	:	1942736947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI HOME HEALTHCARE INCORPORATED

Provider Business Mailing Address
First Line	:	12201 W NORTH AVE
Second Line	:	SUITE 101
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2061
Country	:	US
Telephone Number	:	414-204-8462
Fax Number	:	262-342-2673

Provider Business Practice Location Address
First Line	:	12201 W NORTH AVE
Second Line	:	SUITE 101
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-2061
Country	:	US
Telephone Number	:	414-204-8462
Fax Number	:	262-342-2673

Authorized Official
Title or Position	:	ADMINISTRATIVE DIRECTOR
Name	:	KIANTE SHIELDS
Credential	:
Telephone Number	:	414-213-6335

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	05/11/2017

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