Healthcare Provider Details

I. General information

NPI: 1336351634
Provider Name (Legal Business Name): MRS. SHALANDA M ODOM-MACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SHALANDA M ODOM

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11305 KEPPLER CT
CLEVELAND OH
44105-6242
US

IV. Provider business mailing address

11305 KEPPLER CT
CLEVELAND OH
44105-6242
US

V. Phone/Fax

Practice location:
  • Phone: 216-801-2700
  • Fax: 216-801-2700
Mailing address:
  • Phone: 216-331-1321
  • Fax: 216-331-1321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number376939251197
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: