MEDICARE: OMEGA OF NORTH CAROLINA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	1061647	NC

General Provider Information

NPI Number	:	1245489780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMEGA OF NORTH CAROLINA, LLC

Provider Business Mailing Address
First Line	:	110 MEDICAL DR
Second Line	:	SUITE 8
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3374
Country	:	US
Telephone Number	:	252-338-5183
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 MEDICAL DR
Second Line	:	SUITE 8
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-3374
Country	:	US
Telephone Number	:	252-338-5183
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MS. KIMBERLY DEANE ELLIS
Credential	:
Telephone Number	:	804-527-5337

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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