Healthcare Provider Details

I. General information

NPI: 1114484391
Provider Name (Legal Business Name): OMEGA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14774 BEACH BLVD
LA MIRADA CA
90638-4250
US

IV. Provider business mailing address

14774 BEACH BLVD
LA MIRADA CA
90638-4250
US

V. Phone/Fax

Practice location:
  • Phone: 714-670-0007
  • Fax: 714-670-0006
Mailing address:
  • Phone: 714-670-0007
  • Fax: 714-670-0006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KYUNG RAN TAE
Title or Position: CEO
Credential: OTR/L
Phone: 714-670-0007