Provider Demographics
NPI:1982937967
Name:ODEMBO, GEORGE
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:ODEMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 PATTON DRIVE, SUITE C.
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4696
Mailing Address - Country:US
Mailing Address - Phone:704-487-4440
Mailing Address - Fax:704-487-1511
Practice Address - Street 1:213 PATTON DR STE C
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4674
Practice Address - Country:US
Practice Address - Phone:704-487-4440
Practice Address - Fax:704-487-1511
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC251C00000XOther251C00000X TAXONOMY
NC251B00000XOther251B00000X TAXONOMY
NC251S00000XOther251S00000X TAXONOMY
NC1255640165OtherNPPES NPI