Provider Demographics
NPI:1477107365
Name:OMNI HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:OMNI HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IBETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-637-6249
Mailing Address - Street 1:7646 FOREST GLEN WAY
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-6867
Mailing Address - Country:US
Mailing Address - Phone:678-637-6249
Mailing Address - Fax:404-393-4950
Practice Address - Street 1:560 THORNTON RD STE 214
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-1656
Practice Address - Country:US
Practice Address - Phone:678-637-6249
Practice Address - Fax:404-393-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-29
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1053807347OtherNPPES
GA003207509AMedicaid