Provider Demographics
NPI:1881257202
Name:SUSAN ODERWALD LLC
Entity type:Organization
Organization Name:SUSAN ODERWALD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ODERWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-297-3589
Mailing Address - Street 1:3 SCHOONER LN UNIT 1-1
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3377
Mailing Address - Country:US
Mailing Address - Phone:203-877-1377
Mailing Address - Fax:
Practice Address - Street 1:3 SCHOONER LN UNIT 1-1
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3377
Practice Address - Country:US
Practice Address - Phone:203-877-1377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-22
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care