Provider Demographics
NPI:1508150129
Name:OMNI CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:OMNI CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-422-2025
Mailing Address - Street 1:6902 W LINEBAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-5800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6902 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-5800
Practice Address - Country:US
Practice Address - Phone:813-422-2025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 9629111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000581000Medicaid
FL000581000Medicaid