1801497912 NPI number — MR. CHRISTIAN E ODOM

Table of content: MR. CHRISTIAN E ODOM (NPI 1801497912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801497912 NPI number — MR. CHRISTIAN E ODOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODOM
Provider First Name:
CHRISTIAN
Provider Middle Name:
E
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801497912
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 S ALASKA ST STE 202
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99645-6372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-746-6019
Provider Business Mailing Address Fax Number:
907-745-7565

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 S ALASKA ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99645-6372
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-746-6019
Provider Business Practice Location Address Fax Number:
907-745-7565
Provider Enumeration Date:
11/04/2020

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1811042872 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com