Healthcare Provider Details

I. General information

NPI: 1316929060
Provider Name (Legal Business Name): MARCELLA RAQUEL ODEN PT, DPT, DACM, L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 GENESEE AVE
SAN DIEGO CA
92117-3005
US

IV. Provider business mailing address

315 B AVE
CORONADO CA
92118-1925
US

V. Phone/Fax

Practice location:
  • Phone: 619-800-1974
  • Fax:
Mailing address:
  • Phone: 808-783-4330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number27789
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number19467
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberPT27789
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: