Healthcare Provider Details

I. General information

NPI: 1760746739
Provider Name (Legal Business Name): OMM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 OVERLOOK RD STE 140
SUMMIT NJ
07901-3577
US

IV. Provider business mailing address

11 OVERLOOK RD STE 140
SUMMIT NJ
07901-3577
US

V. Phone/Fax

Practice location:
  • Phone: 973-507-6327
  • Fax:
Mailing address:
  • Phone: 973-507-6327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberMB36416
License Number StateNJ

VIII. Authorized Official

Name: STEVEN LEVINE
Title or Position: PHYSICIAN
Credential: D.O
Phone: 973-507-6327