Healthcare Provider Details

I. General information

NPI: 1629463344
Provider Name (Legal Business Name): ODOM HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 10TH ST
SILVIS IL
61282-1909
US

IV. Provider business mailing address

10500 WAYZATA BLVD
MINNETONKA MN
55305-1511
US

V. Phone/Fax

Practice location:
  • Phone: 309-278-1537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070020938
License Number StateIL

VIII. Authorized Official

Name: NICOLE NASH
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 952-224-1919