Basic Information
| Provider Information | |||||||||
| NPI: | 1912306382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OMNI COMMUNITY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S. PERIMETER PARK DRIVE | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372114128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157263603 | ||||||||
| FaxNumber: | 6158270421 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 THOMPSON LANE | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372112411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157810013 | ||||||||
| FaxNumber: | 6157810688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2014 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | JUST | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6157263603 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 13784 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | Q019946 | 05 | TN | MEDICAID | 3376955 | 05 | TN | MEDICAID |