1336351634 NPI number — MRS. SHALANDA M ODOM-MACK

Table of content: MRS. SHALANDA M ODOM-MACK (NPI 1336351634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336351634 NPI number — MRS. SHALANDA M ODOM-MACK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODOM-MACK
Provider First Name:
SHALANDA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ODOM
Provider Other First Name:
SHALANDA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336351634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11305 KEPPLER CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44105-6242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-331-1321
Provider Business Mailing Address Fax Number:
216-331-1321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11305 KEPPLER CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44105-6242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-801-2700
Provider Business Practice Location Address Fax Number:
216-801-2700
Provider Enumeration Date:
05/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X , with the licence number:  376939251197 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2365435 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com