Healthcare Provider Details

I. General information

NPI: 1275833287
Provider Name (Legal Business Name): BRIAN HEATH ODOM PT, CWS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDRENS WAY
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1192
  • Fax: 501-364-3564
Mailing address:
  • Phone: 501-364-1192
  • Fax: 501-364-3564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2398
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: