MEDICARE: OMEGAQUANT

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	DL019088	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	43D1105229	OTHER	SD	CLIA

General Provider Information

NPI Number	:	1306291901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMEGAQUANT

Provider Business Mailing Address
First Line	:	5009 W 12TH ST
Second Line	:	SUITE 8
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3988
Country	:	US
Telephone Number	:	605-271-6917
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 W 12TH ST
Second Line	:	SUITE 8
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3988
Country	:	US
Telephone Number	:	605-271-6917
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM STEPHEN HARRIS
Credential	:	PHD
Telephone Number	:	605-271-6917

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	05/02/2016

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Directions to “OMEGAQUANT ” Practice Location

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