=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669501516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | O'DELL FAMILY CHIROPRACTIC CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 05/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28245 SOUTHFIELD RD
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-552-1110
-----------------------------------------------------
Fax | 248-552-0771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28245 SOUTHFIELD RD
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-552-1110
-----------------------------------------------------
Fax | 248-552-0771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KEVIN J. O'DELL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 248-552-1110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301006957
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------