Provider Demographics
NPI:1225743636
Name:ODA, KAILIE MIDORI (PTA)
Entity Type:Individual
Prefix:
First Name:KAILIE
Middle Name:MIDORI
Last Name:ODA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 TROON DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9749
Mailing Address - Country:US
Mailing Address - Phone:801-589-5880
Mailing Address - Fax:
Practice Address - Street 1:3024 W 300 N STE B
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:UT
Practice Address - Zip Code:84015-7259
Practice Address - Country:US
Practice Address - Phone:801-825-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant