Provider Demographics
NPI:1053830810
Name:ODOM, KELSEY MARIE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 THREE CHOP RUN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9216
Mailing Address - Country:US
Mailing Address - Phone:803-960-9855
Mailing Address - Fax:
Practice Address - Street 1:731 POLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4462
Practice Address - Country:US
Practice Address - Phone:803-788-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant