Provider Demographics
NPI:1063991735
Name:OMNI LABORATORY SERVICES
Entity type:Organization
Organization Name:OMNI LABORATORY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GULAM TAHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-200-8059
Mailing Address - Street 1:5866 N LINCOLN AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-4632
Mailing Address - Country:US
Mailing Address - Phone:773-200-8059
Mailing Address - Fax:
Practice Address - Street 1:5866 N LINCOLN AVE
Practice Address - Street 2:STE 103
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4632
Practice Address - Country:US
Practice Address - Phone:773-200-8059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory