Provider Demographics
NPI:1700050804
Name:OMEGA II, LLC
Entity Type:Organization
Organization Name:OMEGA II, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:TKACIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-379-8113
Mailing Address - Street 1:419 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-2237
Mailing Address - Country:US
Mailing Address - Phone:716-379-8113
Mailing Address - Fax:716-379-8115
Practice Address - Street 1:419 N 8TH ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2237
Practice Address - Country:US
Practice Address - Phone:716-379-8113
Practice Address - Fax:716-379-8115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161469207R00000X
NY004883-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty