Provider Demographics
NPI:1619081437
Name:OMNE CLINIC, INC.
Entity Type:Organization
Organization Name:OMNE CLINIC, INC.
Other - Org Name:ECP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMETS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PSYD
Authorized Official - Phone:715-514-4600
Mailing Address - Street 1:101 N. FARWELL STREET
Mailing Address - Street 2:STE. 204
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703
Mailing Address - Country:US
Mailing Address - Phone:715-514-4600
Mailing Address - Fax:715-514-4008
Practice Address - Street 1:101 N. FARWELL STREET
Practice Address - Street 2:STE. 204
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703
Practice Address - Country:US
Practice Address - Phone:715-514-4600
Practice Address - Fax:715-514-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1720103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI412144500Medicaid
84659Medicare PIN