Healthcare Provider Details

I. General information

NPI: 1700707080
Provider Name (Legal Business Name): OMEGA 12 MANAGEMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 184
WALL TX
76957-0184
US

IV. Provider business mailing address

PO BOX 184
WALL TX
76957-0184
US

V. Phone/Fax

Practice location:
  • Phone: 940-364-4007
  • Fax:
Mailing address:
  • Phone: 940-364-4007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MILES RAIZADA
Title or Position: PHYSICIAN
Credential: MD
Phone: 940-364-4007