Provider Demographics
NPI:1750695094
Name:ONMO LLC
Entity type:Organization
Organization Name:ONMO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:BOSAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-458-4648
Mailing Address - Street 1:1939 FRONTAGE RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4638
Mailing Address - Country:US
Mailing Address - Phone:520-458-4648
Mailing Address - Fax:520-459-7945
Practice Address - Street 1:1939 FRONTAGE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4638
Practice Address - Country:US
Practice Address - Phone:520-458-4648
Practice Address - Fax:520-459-7945
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAPHA MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-28
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588794192OtherPERSONAL NPI