Healthcare Provider Details

I. General information

NPI: 1700050804
Provider Name (Legal Business Name): OMEGA II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 N 8TH ST
OLEAN NY
14760-2237
US

IV. Provider business mailing address

419 N 8TH ST
OLEAN NY
14760-2237
US

V. Phone/Fax

Practice location:
  • Phone: 716-379-8113
  • Fax: 716-379-8115
Mailing address:
  • Phone: 716-379-8113
  • Fax: 716-379-8115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number161469
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004883-1
License Number StateNY

VIII. Authorized Official

Name: MR. JAMES E TKACIK
Title or Position: CEO
Credential:
Phone: 716-379-8113