Organization
OMNI PAIN CLINIC INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. AUGUSTA U. IKHISEMOJIE MD (CEO)
(972) 642-5855
Entity
Organization
Contact information
Practice address
513 W JEFFERSON BLVD., SUITE 170, GRAND PRAIRIE, TX 75051-1639
(972) 642-5855
(972) 642-5853
Mailing address
P O BOX 294822, LEWISVILLE, TX 75029-4822
(972) 642-5855
(972) 642-5853
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
P1462
TX
208VP0000X
Pain Medicine Physician
Primary
P1462
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P1462
TEXAS LISENCE
TX
Enumeration date
10/24/2012
Last updated
11/02/2012
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