MEDICARE: ODIN HEALTHCARE PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1538805239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODIN HEALTHCARE PLLC

Provider Business Mailing Address
First Line	:	3151 DALLAS HIGH SHOALS HWY UNIT 935
Second Line	:
City	:	DALLAS
State	:	NC
Zip	:	28034-1369
Country	:	US
Telephone Number	:	803-470-5358
Fax Number	:

Provider Business Practice Location Address
First Line	:	3151 DALLAS HIGH SHOALS HWY UNIT 935
Second Line	:
City	:	DALLAS
State	:	NC
Zip	:	28034-1369
Country	:	US
Telephone Number	:	803-470-5358
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CRYSTAL MARTINEZ
Credential	:	NP
Telephone Number	:	813-817-1135

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	06/15/2022

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Directions to “ODIN HEALTHCARE PLLC ” Practice Location

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