Healthcare Provider Details

I. General information

NPI: 1659240588
Provider Name (Legal Business Name): KENNETH ODOOM DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1886 METRO CENTER DR STE 100
RESTON VA
20190-5289
US

IV. Provider business mailing address

14860 LYNHODGE CT
CENTREVILLE VA
20120-1862
US

V. Phone/Fax

Practice location:
  • Phone: 703-437-8195
  • Fax: 703-437-2404
Mailing address:
  • Phone: 703-437-8195
  • Fax: 703-437-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104558117
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: