Provider Demographics
NPI:1659513653
Name:OMEGA INDEPENDENT LIVING SERVICES, INC.
Entity Type:Organization
Organization Name:OMEGA INDEPENDENT LIVING SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-255-3268
Mailing Address - Street 1:3029 STONY BROOK DR STE 105
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3790
Mailing Address - Country:US
Mailing Address - Phone:919-255-3268
Mailing Address - Fax:
Practice Address - Street 1:2410 PINEY PLAINS RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6868
Practice Address - Country:US
Practice Address - Phone:919-255-3268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-702320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604281Medicaid