Provider Demographics
NPI:1841543097
Name:OMNI PAIN CLINIC INC
Entity type:Organization
Organization Name:OMNI PAIN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTA
Authorized Official - Middle Name:U
Authorized Official - Last Name:IKHISEMOJIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-642-5855
Mailing Address - Street 1:P O BOX 294822
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75029-4822
Mailing Address - Country:US
Mailing Address - Phone:972-642-5855
Mailing Address - Fax:972-642-5853
Practice Address - Street 1:513 W JEFFERSON BLVD.
Practice Address - Street 2:SUITE 170
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1639
Practice Address - Country:US
Practice Address - Phone:972-642-5855
Practice Address - Fax:972-642-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1462207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP1462OtherTEXAS LISENCE