Provider Demographics
NPI:1245787811
Name:ODOMRD, LLC
Entity Type:Organization
Organization Name:ODOMRD, LLC
Other - Org Name:ODOMRD DIETITIAN CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:HELD
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:MPH RD LD
Authorized Official - Phone:325-262-2133
Mailing Address - Street 1:2533 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-3653
Mailing Address - Country:US
Mailing Address - Phone:325-262-2133
Mailing Address - Fax:
Practice Address - Street 1:2533 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-3653
Practice Address - Country:US
Practice Address - Phone:325-262-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81387133V00000X
TXDT83185133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty