Provider Demographics
NPI:1336782812
Name:OMNI MEDICAL SUPPLY INC
Entity type:Organization
Organization Name:OMNI MEDICAL SUPPLY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-664-0032
Mailing Address - Street 1:5518 PARK THICKET LN
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-2144
Mailing Address - Country:US
Mailing Address - Phone:866-542-3020
Mailing Address - Fax:281-431-3824
Practice Address - Street 1:5518 PARK THICKET LN
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-2144
Practice Address - Country:US
Practice Address - Phone:888-664-0032
Practice Address - Fax:346-816-7690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-28
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4096315-01Medicaid