Healthcare Provider Details

I. General information

NPI: 1811468127
Provider Name (Legal Business Name): OMNI HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2018
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E BROAD ST STE 4
HAZLETON PA
18201-5657
US

IV. Provider business mailing address

PO BOX 454
MONTGOMERYVILLE PA
18936-0454
US

V. Phone/Fax

Practice location:
  • Phone: 570-455-0322
  • Fax: 570-455-0566
Mailing address:
  • Phone: 215-997-2000
  • Fax: 215-997-2282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1020016630010
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: MICHAEL M THEVAR
Title or Position: PRESIDENT
Credential:
Phone: 215-997-2000