Provider Demographics
NPI:1861982423
Name:OMNI WELLNESS GROUP LLC
Entity type:Organization
Organization Name:OMNI WELLNESS GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETREQUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-438-9500
Mailing Address - Street 1:1149 EXPERIMENT FARM RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1071
Mailing Address - Country:US
Mailing Address - Phone:937-438-9500
Mailing Address - Fax:937-886-5694
Practice Address - Street 1:1149 EXPERIMENT FARM ROAD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373
Practice Address - Country:US
Practice Address - Phone:937-540-9920
Practice Address - Fax:937-202-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-18
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty