Provider Demographics
NPI:1598736985
Name:OMNI HEALTHCARE, INC.
Entity Type:Organization
Organization Name:OMNI HEALTHCARE, INC.
Other - Org Name:MELBOURNE MEDICAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:DELIGDISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-722-1766
Mailing Address - Street 1:95 BULLDOG BLVD
Mailing Address - Street 2:STE 202
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3332
Mailing Address - Country:US
Mailing Address - Phone:321-727-2990
Mailing Address - Fax:321-724-0455
Practice Address - Street 1:95 BULLDOG BLVD
Practice Address - Street 2:STE 202
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3332
Practice Address - Country:US
Practice Address - Phone:321-722-1766
Practice Address - Fax:321-722-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-01
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800027101291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374370500-17Medicaid
FL374370500-17Medicaid
FL030372100Medicaid