Provider Demographics
NPI:1922438829
Name:OMAHA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OMAHA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:CHANLATTE-GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-588-0678
Mailing Address - Street 1:9015 ARBOR ST STE 144
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2072
Mailing Address - Country:US
Mailing Address - Phone:402-588-0678
Mailing Address - Fax:402-588-0678
Practice Address - Street 1:9015 ARBOR ST STE 144
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-2072
Practice Address - Country:US
Practice Address - Phone:402-588-0678
Practice Address - Fax:402-588-0678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty