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General NPI Number Information
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NPI Number | 1629463344
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Entity Type | Organization
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Legal Business Name | ODOM HEALTH AND WELLNESS
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 1900 10TH ST
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City | SILVIS
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State | IL
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Zip | 61282-1909
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Country | US
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Telephone | 309-278-1537
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Fax |
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Provider Business Mailing Address
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Address Line | 10500 WAYZATA BLVD
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City | MINNETONKA
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State | MN
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Zip | 55305-1511
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | NICOLE NASH
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Credential |
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Telephone | 952-224-1919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 070020938
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License Number State | IL
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