Provider Demographics
NPI:1457548604
Name:OMNICARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:OMNICARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON-CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-605-0000
Mailing Address - Street 1:3680 E IMPERIAL HWY
Mailing Address - Street 2:SUITE 480
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-2659
Mailing Address - Country:US
Mailing Address - Phone:310-605-0000
Mailing Address - Fax:310-605-0051
Practice Address - Street 1:3680 E IMPERIAL HWY
Practice Address - Street 2:SUITE 480
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2659
Practice Address - Country:US
Practice Address - Phone:310-605-0000
Practice Address - Fax:310-605-0051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNICARE MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization