Provider Demographics
NPI:1245489780
Name:OMEGA OF NORTH CAROLINA, LLC
Entity type:Organization
Organization Name:OMEGA OF NORTH CAROLINA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:DEANE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-527-5337
Mailing Address - Street 1:110 MEDICAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3374
Mailing Address - Country:US
Mailing Address - Phone:252-338-5183
Mailing Address - Fax:
Practice Address - Street 1:110 MEDICAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3374
Practice Address - Country:US
Practice Address - Phone:252-338-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1061647291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory