Healthcare Provider Details

I. General information

NPI: 1386248714
Provider Name (Legal Business Name): OMNI INTEGRATIVE WELLNESS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2020
Last Update Date: 11/25/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 HADLEY MILL RD
JACKSON ME
04921-3119
US

IV. Provider business mailing address

PO BOX 115
BROOKS ME
04921-0115
US

V. Phone/Fax

Practice location:
  • Phone: 207-505-6082
  • Fax:
Mailing address:
  • Phone: 207-505-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LISA AUDINO
Title or Position: COO
Credential: LCSW, CADC
Phone: 207-505-6082