Provider Demographics
NPI:1679528822
Name:OMNI FAMILY MEDICAL CLINIC SC
Entity Type:Organization
Organization Name:OMNI FAMILY MEDICAL CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABALO
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNYAKPE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-586-9255
Mailing Address - Street 1:4555 WEST SCHROEDER DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223
Mailing Address - Country:US
Mailing Address - Phone:414-365-3210
Mailing Address - Fax:414-365-3225
Practice Address - Street 1:7810 WEST GOOD HOPE ROAD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223
Practice Address - Country:US
Practice Address - Phone:414-586-9255
Practice Address - Fax:414-586-9282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21290800Medicaid