Provider Demographics
NPI:1194905695
Name:RANDY A. OMLOR, OD PA
Entity type:Organization
Organization Name:RANDY A. OMLOR, OD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:OMLOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MS
Authorized Official - Phone:828-657-0016
Mailing Address - Street 1:1415 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3406
Mailing Address - Country:US
Mailing Address - Phone:704-487-4099
Mailing Address - Fax:
Practice Address - Street 1:1415 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3406
Practice Address - Country:US
Practice Address - Phone:704-487-4099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2039152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215038898OtherINDIVIDUAL NPI
NC2474340BMedicare PIN