Provider Demographics
NPI:1033572227
Name:OMNI COMMUNITY HEALTH
Entity type:Organization
Organization Name:OMNI COMMUNITY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-726-3603
Mailing Address - Street 1:301 S PERIMETER PARK DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-4128
Mailing Address - Country:US
Mailing Address - Phone:615-726-3603
Mailing Address - Fax:615-827-0421
Practice Address - Street 1:4709 PAPERMILL DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1928
Practice Address - Country:US
Practice Address - Phone:865-525-0391
Practice Address - Fax:865-381-1205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17806251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ020542Medicaid