=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821306515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNI DIVINE HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2010
-----------------------------------------------------
Last Update Date | 09/16/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10039 BISSONNET ST 218
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77036-7854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-701-7850
-----------------------------------------------------
Fax | 713-777-3418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10039 BISSONNET ST STE 218
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77036-7852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-701-7850
-----------------------------------------------------
Fax | 713-777-3418
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. VICTOR C. VICTOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-701-7850
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------