Healthcare Provider Details

I. General information

NPI: 1619115995
Provider Name (Legal Business Name): ODOM CHIROPRACTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6125 INTERSTATE 20 302
FORT WORTH TX
76132-3629
US

IV. Provider business mailing address

6125 INTERSTATE 20 302
FORT WORTH TX
76132-3629
US

V. Phone/Fax

Practice location:
  • Phone: 817-738-9777
  • Fax: 817-738-8708
Mailing address:
  • Phone: 817-738-9777
  • Fax: 817-738-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberDC5994
License Number StateTX

VIII. Authorized Official

Name: DR. TIMOTHY E ODOM
Title or Position: OWNER
Credential: D.C
Phone: 817-738-9777