Healthcare Provider Details

I. General information

NPI: 1679178206
Provider Name (Legal Business Name): OMSCOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 WALL ST
POWDERSVILLE SC
29673-6754
US

IV. Provider business mailing address

1140 WOODRUFF RD STE 106-180
GREENVILLE SC
29607-4172
US

V. Phone/Fax

Practice location:
  • Phone: 864-420-2738
  • Fax:
Mailing address:
  • Phone: 864-420-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRETT SHIGLEY
Title or Position: PRESIDENT
Credential: DMD, MS
Phone: 864-420-2738