Basic Information
| Provider Information | |||||||||
| NPI: | 1528664448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMELANCZUK | ||||||||
| FirstName: | MARINO | ||||||||
| MiddleName: | ADRIAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 S 9TH ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | NOBLESVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460602631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172043736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5620 SOHL AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463202008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199379085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2020 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06006214A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.