Provider Demographics
NPI:1144396391
Name:PRIVATELY YOURS BY OMA
Entity Type:Organization
Organization Name:PRIVATELY YOURS BY OMA
Other - Org Name:OMA LOUISE P WILSON
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMA
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-789-2354
Mailing Address - Street 1:2413 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456
Mailing Address - Country:US
Mailing Address - Phone:315-789-2354
Mailing Address - Fax:
Practice Address - Street 1:1943 ROUTE 14 N
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456
Practice Address - Country:US
Practice Address - Phone:315-789-2354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NO LISCENSE REQUIRED332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00757199Medicaid
NYOW241144OtherEXCELLUS BLUE CROSS BLUE
NY111353AUOtherPREFERRED CARE
NYOW241144OtherEXCELLUS BLUE CROSS BLUE