Healthcare Provider Details

I. General information

NPI: 1619081437
Provider Name (Legal Business Name): OMNE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N. FARWELL STREET STE. 204
EAU CLAIRE WI
54703
US

IV. Provider business mailing address

101 N. FARWELL STREET STE. 204
EAU CLAIRE WI
54703
US

V. Phone/Fax

Practice location:
  • Phone: 715-514-4600
  • Fax: 715-514-4008
Mailing address:
  • Phone: 715-514-4600
  • Fax: 715-514-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number1720
License Number StateWI

VIII. Authorized Official

Name: ANTON C SMETS
Title or Position: OWNER/PRESIDENT
Credential: PH.D, PSY.D.
Phone: 715-514-4600