Provider Demographics
NPI:1922761451
Name:ODOM, TAJAYLAH LAKAISHA
Entity Type:Individual
Prefix:
First Name:TAJAYLAH
Middle Name:LAKAISHA
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 W DORCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-2434
Mailing Address - Country:US
Mailing Address - Phone:864-535-1298
Mailing Address - Fax:
Practice Address - Street 1:701 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29733-7001
Practice Address - Country:US
Practice Address - Phone:803-323-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program