Provider Demographics
NPI:1568768042
Name:OMNI MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OMNI MEDICAL GROUP LLC
Other - Org Name:CLINICA LA ESPERANZA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:OLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DZIUBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-573-2495
Mailing Address - Street 1:4201 CENTRAL AVE NW
Mailing Address - Street 2:STE K3
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-1630
Mailing Address - Country:US
Mailing Address - Phone:505-508-1739
Mailing Address - Fax:
Practice Address - Street 1:4201 CENTRAL AVE NW
Practice Address - Street 2:K3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-1630
Practice Address - Country:US
Practice Address - Phone:505-717-1685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6556204C00000X
207Q00000X, 261Q00000X
NMPA20030032363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM5126223Medicaid