=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679362396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNIMED WELLNESS SOLUTIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2025
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10202 PERKINS ROWE STE E160
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70810-2067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-610-9447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 872
-----------------------------------------------------
City | SAINT GABRIEL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70776-0872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-610-9447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. CORINTHIUS NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-610-9447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------