Healthcare Provider Details

I. General information

NPI: 1780103093
Provider Name (Legal Business Name): TATE ODELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 ROSE CT APT 1
SNYDER NY
14226-3661
US

IV. Provider business mailing address

35 ROSE CT APT 1
SNYDER NY
14226-3661
US

V. Phone/Fax

Practice location:
  • Phone: 802-299-9710
  • Fax:
Mailing address:
  • Phone: 802-299-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: