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General NPI Number Information
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NPI Number | 1245489780
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Entity Type | Organization
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Legal Business Name | OMEGA OF NORTH CAROLINA, LLC
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Dates
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Enumeration Date | 09/09/2008
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Last Update Date | 09/09/2008
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Provider Practice Location Address
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Address Line | 110 MEDICAL DR SUITE 8
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City | ELIZABETH CITY
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State | NC
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Zip | 27909-3374
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Country | US
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Telephone | 252-338-5183
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Fax |
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Provider Business Mailing Address
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Address Line | 110 MEDICAL DR SUITE 8
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City | ELIZABETH CITY
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State | NC
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Zip | 27909-3374
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Country | US
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Telephone | 252-338-5183
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MS. KIMBERLY DEANE ELLIS
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Credential |
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Telephone | 804-527-5337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 1061647
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License Number State | NC
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