=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093903049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNA BONE ODOM, D.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2007
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7734 WATSON RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-1807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7734 WATSON RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63119-5407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-961-1807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANNA BONE ODOM
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 704-501-7552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3441
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------