Provider Demographics
NPI:1548794886
Name:OMNIS HEALTH LIFE, LLC
Entity Type:Organization
Organization Name:OMNIS HEALTH LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRWOMAN
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-204-5594
Mailing Address - Street 1:162 PONTE VEDRA DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-8040
Mailing Address - Country:US
Mailing Address - Phone:667-212-4187
Mailing Address - Fax:
Practice Address - Street 1:2200 GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2619
Practice Address - Country:US
Practice Address - Phone:667-212-4187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-13
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X, 261QR0405X
MDBH00175261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone