Healthcare Provider Details

I. General information

NPI: 1790748960
Provider Name (Legal Business Name): OMNI CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 OFFICE PARK DR
JACKSONVILLE NC
28546-7325
US

IV. Provider business mailing address

PO BOX 12353
JACKSONVILLE NC
28546-2353
US

V. Phone/Fax

Practice location:
  • Phone: 910-219-4070
  • Fax: 910-219-4071
Mailing address:
  • Phone: 910-219-4070
  • Fax: 910-219-4071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number9901455
License Number StateNC

VIII. Authorized Official

Name: MRS. TERESA BURKETT
Title or Position: OFFICE SUPERVISOR
Credential:
Phone: 910-219-4070