Healthcare Provider Details

I. General information

NPI: 1891422341
Provider Name (Legal Business Name): OMNIBUS MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E SAHARA AVE STE 133
LAS VEGAS NV
89104-3707
US

IV. Provider business mailing address

1810 E SAHARA AVE STE 133
LAS VEGAS NV
89104-3707
US

V. Phone/Fax

Practice location:
  • Phone: 323-590-9128
  • Fax:
Mailing address:
  • Phone: 323-590-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CODY HALL
Title or Position: MANAGER
Credential:
Phone: 704-617-8535