Provider Demographics
NPI:1164945267
Name:ODUM, ELAINE MARIE (ATC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARIE
Last Name:ODUM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 WALNUT CREEK CT
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-8179
Mailing Address - Country:US
Mailing Address - Phone:913-375-5958
Mailing Address - Fax:
Practice Address - Street 1:1605 AVENUE OF CHAMPIONS
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6412
Practice Address - Country:US
Practice Address - Phone:270-745-3743
Practice Address - Fax:270-745-4106
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer