Provider Demographics
NPI:1629463344
Name:ODOM HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:ODOM HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-224-1919
Mailing Address - Street 1:10500 WAYZATA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 10TH ST
Practice Address - Street 2:
Practice Address - City:SILVIS
Practice Address - State:IL
Practice Address - Zip Code:61282-1909
Practice Address - Country:US
Practice Address - Phone:309-278-1537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070020938261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy