=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508824251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMEGA NUCLEAR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2006
-----------------------------------------------------
Last Update Date | 12/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | L12 OMEGA DRIVE
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-368-8150
-----------------------------------------------------
Fax | 302-368-3412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 MILLTOWN RD SUITE 13
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19808-4027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-993-2330
-----------------------------------------------------
Fax | 302-993-2344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROJECT MANAGER
-----------------------------------------------------
Name | VICTORIA L PEACOCK
-----------------------------------------------------
Credential | MS, MS
-----------------------------------------------------
Telephone | 302-993-2330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085N0904X
-----------------------------------------------------
Taxonomy Name | Nuclear Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------