MEDICARE: OMNI HUMAN SERVICES, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1407188444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI HUMAN SERVICES, LLC

Provider Business Mailing Address
First Line	:	109 BEAU PKWY
Second Line	:	D
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-7767
Country	:	US
Telephone Number	:	252-337-7668
Fax Number	:	252-337-6304

Provider Business Practice Location Address
First Line	:	109 BEAU PKWY
Second Line	:	D
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-7767
Country	:	US
Telephone Number	:	252-337-7668
Fax Number	:	252-337-6304

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. WENDELINE SCANTLING MCLAIN
Credential	:	BS/QP
Telephone Number	:	910-818-1236

Provider Enumeration Date	:	02/01/2010
Last Update Date	:	02/01/2010

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