MEDICARE: OMNICORE HEALTH SERVICES, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103T00000X	Psychologist
2	1041C0700X	Clinical Social Worker
3	101YA0400X	Addiction (Substance Use Disorder) Counselor
4	106H00000X	Marriage & Family Therapist
5	101YM0800X	Mental Health Counselor
6	106S00000X	Behavior Technician
7	167G00000X	Licensed Psychiatric Technician
8	207R00000X	Internal Medicine Physician
9	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
10	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1275318818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNICORE HEALTH SERVICES, INC

Provider Business Mailing Address
First Line	:	363 S INDIAN HILL BLVD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-5224
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	363 S INDIAN HILL BLVD
Second Line	:
City	:	CLAREMONT
State	:	CA
Zip	:	91711-5224
Country	:	US
Telephone Number	:	909-929-0070
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MALLU REDDY
Credential	:	MD
Telephone Number	:	909-635-7764

Provider Enumeration Date	:	08/30/2023
Last Update Date	:	04/10/2024

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