Provider Demographics
NPI:1639350770
Name:OMNI WELLNESS CENTER PLLC
Entity Type:Organization
Organization Name:OMNI WELLNESS CENTER PLLC
Other - Org Name:OMNI WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-392-9999
Mailing Address - Street 1:10220 COULOAK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-7678
Mailing Address - Country:US
Mailing Address - Phone:704-392-9999
Mailing Address - Fax:704-392-9913
Practice Address - Street 1:10220 COULOAK DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7678
Practice Address - Country:US
Practice Address - Phone:704-392-9999
Practice Address - Fax:704-392-9913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908653Medicaid
NC1861264111Medicaid
NC1679068464Medicaid
NC1811485378Medicaid