Healthcare Provider Details

I. General information

NPI: 1063123933
Provider Name (Legal Business Name): OMS PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2022
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2145 ROSWELL RD STE 60
MARIETTA GA
30062-0819
US

IV. Provider business mailing address

2145 ROSWELL RD STE 60
MARIETTA GA
30062-0819
US

V. Phone/Fax

Practice location:
  • Phone: 770-672-6267
  • Fax: 770-485-8665
Mailing address:
  • Phone: 770-672-6267
  • Fax: 770-485-8665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: OMOKHUALE OMOKHODION
Title or Position: OWNER
Credential: M.D
Phone: 770-672-6267