Provider Demographics
NPI:1215551379
Name:OMEGA MDX-ID LLC
Entity Type:Organization
Organization Name:OMEGA MDX-ID LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVEK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-621-8820
Mailing Address - Street 1:2915 MISSOURI AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-4327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5525 MOUNES ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70123-3215
Practice Address - Country:US
Practice Address - Phone:318-621-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMEGA DIAGNOSTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-04
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory