Healthcare Provider Details

I. General information

NPI: 1821971326
Provider Name (Legal Business Name): COLE SHANE ODOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2025
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 S. FORK AVE
NAMPA ID
83686
US

IV. Provider business mailing address

3420 S FORK AVE
NAMPA ID
83686-4856
US

V. Phone/Fax

Practice location:
  • Phone: 208-250-7733
  • Fax:
Mailing address:
  • Phone: 970-589-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: