Provider Demographics
NPI:1891020111
Name:OMNI PRIMARY CARE CENTER
Entity Type:Organization
Organization Name:OMNI PRIMARY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECREATARY
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-755-5557
Mailing Address - Street 1:975 E 3RD ST
Mailing Address - Street 2:EMC #330
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-8021
Mailing Address - Fax:
Practice Address - Street 1:1000 E 3RD ST
Practice Address - Street 2:#300
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2106
Practice Address - Country:US
Practice Address - Phone:423-778-8021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty