MEDICARE: MR. FRIDAY A. ODONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	H13-00216-6-108724	NV

General Provider Information

NPI Number	:	1194788398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FRIDAY A. ODONG

Provider Business Mailing Address
First Line	:	2306 STOCKTON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-3823
Country	:	US
Telephone Number	:	702-457-0624
Fax Number	:	702-310-4653

Provider Business Practice Location Address
First Line	:	4015 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1612
Country	:	US
Telephone Number	:	702-457-0624
Fax Number	:	702-310-4653

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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