Healthcare Provider Details

I. General information

NPI: 1861312175
Provider Name (Legal Business Name): OMARI BANNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 RAVENSWOOD RD
WALTHAM MA
02453-1747
US

IV. Provider business mailing address

49 RAVENSWOOD RD
WALTHAM MA
02453-1747
US

V. Phone/Fax

Practice location:
  • Phone: 781-547-1713
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17561
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: