Provider Demographics
NPI:1972921302
Name:OMNICARE LABS OF CHAMPAIGN INC
Entity Type:Organization
Organization Name:OMNICARE LABS OF CHAMPAIGN INC
Other - Org Name:OMNI PROSTHETICS AND ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CPO/L
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO/L
Authorized Official - Phone:217-344-6664
Mailing Address - Street 1:502 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-4220
Mailing Address - Country:US
Mailing Address - Phone:217-344-6664
Mailing Address - Fax:217-344-9282
Practice Address - Street 1:201 RICHMOND AVE E
Practice Address - Street 2:STE 5
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4665
Practice Address - Country:US
Practice Address - Phone:217-235-6664
Practice Address - Fax:217-235-6655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNICARE LABS OF CHAMPAIGN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL211000198335E00000X
IL213000216335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid