MEDICARE: MARCELLA RAQUEL ODEN PT, DPT, DACM, L.AC.

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	2251X0800X	Orthopedic Physical Therapist	27789	CA
2	171100000X	Acupuncturist	19467	CA
3	171000000X	Military Health Care Provider	PT27789	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19467	OTHER	CA	ACUPUNCTURE LICENSE
2	AP4491	OTHER	FL	ACUPUNCTURE LICENSE
3	PT27789	OTHER	CA	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1316929060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCELLA RAQUEL ODEN PT, DPT, DACM, L.AC.

Provider Business Mailing Address
First Line	:	315 B AVE
Second Line	:
City	:	CORONADO
State	:	CA
Zip	:	92118-1925
Country	:	US
Telephone Number	:	808-783-4330
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 GENESEE AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-3005
Country	:	US
Telephone Number	:	619-800-1974
Fax Number	:

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

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	01/22/2024

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