=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336824689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY DENISE O'DELL-BROCK DAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2023
-----------------------------------------------------
Last Update Date | 06/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4611 E SHEA BLVD STE 180
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85028-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-697-1962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 W WESCOTT DR
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85027-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-697-1962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | LAC-000936
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------