Healthcare Provider Details

I. General information

NPI: 1699573337
Provider Name (Legal Business Name): OMNI WELLCARE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 E FLAMINGO RD STE 1
LAS VEGAS NV
89119-5274
US

IV. Provider business mailing address

9142 ASPENDALE RANCH CT
LAS VEGAS NV
89139-7276
US

V. Phone/Fax

Practice location:
  • Phone: 702-573-3317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TRACY GO
Title or Position: PRESIDENT
Credential:
Phone: 702-782-0376