Provider Demographics
NPI:1851342422
Name:O'DELL, BRUCE M (LOTR)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:M
Last Name:O'DELL
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3446 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3615
Mailing Address - Country:US
Mailing Address - Phone:318-880-0058
Mailing Address - Fax:318-880-0059
Practice Address - Street 1:3446 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3615
Practice Address - Country:US
Practice Address - Phone:318-880-0058
Practice Address - Fax:318-880-0059
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ11902225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAZ11902OtherOCCUPATIONAL THERAPY LIC#
LAP00474235OtherRAILROAD MEDICARE