Healthcare Provider Details

I. General information

NPI: 1861537995
Provider Name (Legal Business Name): OMNI PHYSICAL & AQUATIC THERAPY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/21/2022
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 RESEARCH PKWY
WALLINGFORD CT
06492-1929
US

IV. Provider business mailing address

8 RESEARCH PKWY
WALLINGFORD CT
06492-1929
US

V. Phone/Fax

Practice location:
  • Phone: 203-294-1998
  • Fax: 203-294-1189
Mailing address:
  • Phone: 203-294-1998
  • Fax: 203-294-1189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateCT
# 8
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateCT
# 9
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRISHA ANN MAHONEY-RANDALL
Title or Position: BILLING MANAGER
Credential:
Phone: 203-877-0112