Provider Demographics
NPI:1285042184
Name:OMEGA LONG TERM CARE LLC
Entity type:Organization
Organization Name:OMEGA LONG TERM CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:L
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-808-5083
Mailing Address - Street 1:12800 BOENKER LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2438
Mailing Address - Country:US
Mailing Address - Phone:314-551-0338
Mailing Address - Fax:314-551-0336
Practice Address - Street 1:12800 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2438
Practice Address - Country:US
Practice Address - Phone:314-551-0338
Practice Address - Fax:314-551-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137743310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429398209Medicaid
MO2001189801Medicaid
MO207937715Medicaid
MO2083138069Medicaid