Healthcare Provider Details

I. General information

NPI: 1881743805
Provider Name (Legal Business Name): OMNI COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 SOUTH JEFFERSON AVE
COOKEVILLE TN
38501-4011
US

IV. Provider business mailing address

301 S. PERIMETER PARK DRIVE SUITE 210
NASHVILLE TN
37211-4128
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-0051
  • Fax: 931-582-0021
Mailing address:
  • Phone: 615-726-3603
  • Fax: 615-827-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberL 214-017-3653
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberL 214-017-3653
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberL 214-017-3653
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberL 214-017-3653
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberL 214-017-3653
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL 214-017-3653
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL 214-017-3653
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberL214-017-3653
License Number StateTN
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberL 214-017-3653
License Number StateTN
# 10
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberL 214-017-3653
License Number StateTN

VIII. Authorized Official

Name: MARK JUST
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 615-726-3603