=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679947337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNI CARE HOSPICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2015
-----------------------------------------------------
Last Update Date | 05/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6225 DEAN MARTIN DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-509-5276
-----------------------------------------------------
Fax | 702-974-1524
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6225 DEAN MARTIN DR
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89118-3803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-509-5276
-----------------------------------------------------
Fax | 702-974-1524
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/CFP
-----------------------------------------------------
Name | MR. AUGUSTINE FARIAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-349-0706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 7955HPC
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------