=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518846617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. OMNI CRENSHAW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2025
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5427 ROLIND DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36108-5427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-354-4181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5427 ROLIND DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36108-5427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-354-4181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | 6006588
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------