MEDICARE: KAILIE MIDORI ODA PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1225743636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAILIE MIDORI ODA PTA

Provider Business Mailing Address
First Line	:	1395 TROON DR
Second Line	:
City	:	SYRACUSE
State	:	UT
Zip	:	84075-9749
Country	:	US
Telephone Number	:	801-589-5880
Fax Number	:

Provider Business Practice Location Address
First Line	:	3024 W 300 N STE B
Second Line	:
City	:	WEST POINT
State	:	UT
Zip	:	84015-7259
Country	:	US
Telephone Number	:	801-825-7500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2023
Last Update Date	:	01/19/2023

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