=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699143321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNIS REHAB L.L.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2015
-----------------------------------------------------
Last Update Date | 03/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12120 COLONEL GLENN RD STE 5200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72210-2824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-454-4528
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12120 COLONEL GLENN RD STE 6200
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72210-2370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-313-2844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. REX PAUL BRADY DECLERK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 501-454-4528
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 15639
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------