MEDICARE: OMNIA CARE PHYSICIAN 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	261Q00000X	Clinic/Center
2	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1659018018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIA CARE PHYSICIAN SERVICES LLC

Provider Business Mailing Address
First Line	:	350 FALCON RIDGE PKWY STE 101
Second Line	:
City	:	MESQUITE
State	:	NV
Zip	:	89027-8879
Country	:	US
Telephone Number	:	702-849-0585
Fax Number	:	702-849-0614

Provider Business Practice Location Address
First Line	:	350 FALCON RIDGE PKWY STE 101
Second Line	:
City	:	MESQUITE
State	:	NV
Zip	:	89027-8879
Country	:	US
Telephone Number	:	702-849-0585
Fax Number	:	702-849-0614

Authorized Official
Title or Position	:	MEMBER
Name	:	WILLIAM S HOKANSON
Credential	:
Telephone Number	:	435-229-8882

Provider Enumeration Date	:	05/17/2022
Last Update Date	:	05/16/2023

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