Provider Demographics
NPI:1528664448
Name:OMELANCZUK, MARINO ADRIAN (PTA)
Entity type:Individual
Prefix:
First Name:MARINO
Middle Name:ADRIAN
Last Name:OMELANCZUK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S 9TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-2631
Mailing Address - Country:US
Mailing Address - Phone:317-204-3736
Mailing Address - Fax:
Practice Address - Street 1:5620 SOHL AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2008
Practice Address - Country:US
Practice Address - Phone:219-937-9085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006214A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty