1275604993 NPI number — A-OMEGA INC

Table of content: (NPI 1275604993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275604993 NPI number — A-OMEGA INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A-OMEGA INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALPHA-OMEGA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275604993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4203 WOODCOCK DR
Provider Second Line Business Mailing Address:
STE 265
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78228-1320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-737-2674
Provider Business Mailing Address Fax Number:
210-734-2412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4203 WOODCOCK DR
Provider Second Line Business Practice Location Address:
STE 265
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78228-1320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-737-2674
Provider Business Practice Location Address Fax Number:
210-734-2412
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIES
Authorized Official First Name:
MARI
Authorized Official Middle Name:
E
Authorized Official Title or Position:
EXECUTIVE DIRECTOR CLINICAL SERVICE
Authorized Official Telephone Number:
210-737-2674

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 144598301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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