MEDICARE: OMNI PAIN CLINIC 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	207Q00000X	Family Medicine Physician	P1462	TX
2	208VP0000X	Pain Medicine Physician	P1462	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P1462	OTHER	TX	TEXAS LISENCE

General Provider Information

NPI Number	:	1841543097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI PAIN CLINIC INC

Provider Business Mailing Address
First Line	:	P O BOX 294822
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75029-4822
Country	:	US
Telephone Number	:	972-642-5855
Fax Number	:	972-642-5853

Provider Business Practice Location Address
First Line	:	513 W JEFFERSON BLVD.
Second Line	:	SUITE 170
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1639
Country	:	US
Telephone Number	:	972-642-5855
Fax Number	:	972-642-5853

Authorized Official
Title or Position	:	CEO
Name	:	DR. AUGUSTA U. IKHISEMOJIE
Credential	:	MD
Telephone Number	:	972-642-5855

Provider Enumeration Date	:	10/24/2012
Last Update Date	:	11/02/2012

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Directions to “OMNI PAIN CLINIC INC ” Practice Location

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