MEDICARE: OMNIPOTENT HOME ALWAY FROM HOME INC

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1255522751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIPOTENT HOME ALWAY FROM HOME INC

Provider Business Mailing Address
First Line	:	8427 BASSETT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77051-1142
Country	:	US
Telephone Number	:	713-662-0800
Fax Number	:	713-662-0801

Provider Business Practice Location Address
First Line	:	2626 S LOOP W STE 418
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-2648
Country	:	US
Telephone Number	:	713-662-0800
Fax Number	:	713-662-0801

Authorized Official
Title or Position	:	DIRECTOR
Name	:	FIDELIA UCHENNA ODILI
Credential	:
Telephone Number	:	713-662-0800

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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