Provider Demographics
NPI:1194848721
Name:OMEGA SLEEP DISORDERS AND DIAGNOSTIC CENTER, LLC
Entity Type:Organization
Organization Name:OMEGA SLEEP DISORDERS AND DIAGNOSTIC CENTER, LLC
Other - Org Name:OMEGA SLEEP DISORDERS AND DIAGNOSTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-527-5337
Mailing Address - Street 1:5225 HICKORY PARK DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059
Mailing Address - Country:US
Mailing Address - Phone:804-527-5337
Mailing Address - Fax:804-527-5222
Practice Address - Street 1:1121 N ROAD ST
Practice Address - Street 2:SUITE A
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3470
Practice Address - Country:US
Practice Address - Phone:252-338-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG67819Medicare UPIN