=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346636768
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY OMNI HOUSECALLS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2015
-----------------------------------------------------
Last Update Date | 10/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10926 DAVID TAYLOR DRIVE SUITE 120
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-706-6614
-----------------------------------------------------
Fax | 336-450-1846
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10926 DAVID TAYLOR DRIVE SUITE 120
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-706-6614
-----------------------------------------------------
Fax | 336-450-1846
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARY MOTLEY HATCHETT
-----------------------------------------------------
Credential | A-GNP
-----------------------------------------------------
Telephone | 336-706-6614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 600053
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------