Provider Demographics
NPI:1760194344
Name:ODOM, MICHAEL ALLEN (LPN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:ODOM
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:ALLEN
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:5900 N LOTZ RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4331
Mailing Address - Country:US
Mailing Address - Phone:313-673-7494
Mailing Address - Fax:
Practice Address - Street 1:5900 N LOTZ RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4331
Practice Address - Country:US
Practice Address - Phone:734-394-4547
Practice Address - Fax:734-394-4650
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703095116164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse