Healthcare Provider Details

I. General information

NPI: 1154892099
Provider Name (Legal Business Name): OMEGA PSYCHIATRIC SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 SAINT JULIAN PL STE 102
COLUMBIA SC
29204-2402
US

IV. Provider business mailing address

1735 SAINT JULIAN PL STE 102
COLUMBIA SC
29204-2402
US

V. Phone/Fax

Practice location:
  • Phone: 803-497-9611
  • Fax: 803-353-3622
Mailing address:
  • Phone: 803-497-9611
  • Fax: 803-764-2003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIM J GILMORE
Title or Position: CO-OWNER
Credential: PMCNS, ANP
Phone: 803-497-9611