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General NPI Number Information
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NPI Number | 1619115995
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Entity Type | Organization
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Legal Business Name | ODOM CHIROPRACTIC CLINIC
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Dates
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Enumeration Date | 01/26/2009
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Last Update Date | 01/26/2009
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Provider Practice Location Address
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Address Line | 6125 INTERSTATE 20 302
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City | FORT WORTH
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State | TX
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Zip | 76132-3629
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Country | US
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Telephone | 817-738-9777
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Fax | 817-738-8708
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Provider Business Mailing Address
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Address Line | 6125 INTERSTATE 20 302
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City | FORT WORTH
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State | TX
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Zip | 76132-3629
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Country | US
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Telephone | 817-738-9777
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Fax | 817-738-8708
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Authorized Official
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Title or Position | OWNER
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Name | DR. TIMOTHY E ODOM
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Credential | D.C
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Telephone | 817-738-9777
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | DC5994
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License Number State | TX
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