Provider Demographics
| NPI: | 1861537995 |
|---|---|
| Name: | OMNI PHYSICAL & AQUATIC THERAPY CENTER, INC |
| Entity type: | Organization |
| Organization Name: | OMNI PHYSICAL & AQUATIC THERAPY CENTER, INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | BILLING MANAGER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | TRISHA |
| Authorized Official - Middle Name: | ANN |
| Authorized Official - Last Name: | MAHONEY-RANDALL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 203-877-0112 |
| Mailing Address - Street 1: | 8 RESEARCH PKWY |
| Mailing Address - Street 2: | |
| Mailing Address - City: | WALLINGFORD |
| Mailing Address - State: | CT |
| Mailing Address - Zip Code: | 06492-1929 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 203-294-1998 |
| Mailing Address - Fax: | 203-294-1189 |
| Practice Address - Street 1: | 8 RESEARCH PKWY |
| Practice Address - Street 2: | |
| Practice Address - City: | WALLINGFORD |
| Practice Address - State: | CT |
| Practice Address - Zip Code: | 06492-1929 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 203-294-1998 |
| Practice Address - Fax: | 203-294-1189 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-02-20 |
| Last Update Date: | 2022-07-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CT | 111N00000X, 111NR0400X, 225100000X, 2251G0304X, 2251X0800X, 225X00000X | |
| 208D00000X, 261QP2000X, 208100000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
| No | 111NR0400X | Chiropractic Providers | Chiropractor | Rehabilitation | Group - Multi-Specialty |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Multi-Specialty |
| No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CT | 6404254 | Other | UNITED HEALTHCARE |
| CT | A667399 | Other | OXFORD |
| CT | 004173184 | Other | BLUE CARE FAMILY PLAN |
| CT | 712712 | Other | CONNECTICARE |
| CT | 004173184 | Medicaid | |
| CT | 004255271 | Medicaid | |
| CT | 0V1691 | Other | HEALTHNET |
| CT | 183158 | Other | FIRST CHOICE |
| CT | 552470 | Other | AETNA |
| CT | 004173184 | Medicaid | |
| CT | 004173184 | Medicaid | |
| CT | 004173184 | Other | BLUE CARE FAMILY PLAN |
