1982937967 NPI number — GEORGE ODEMBO

Table of content: GEORGE ODEMBO (NPI 1982937967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982937967 NPI number — GEORGE ODEMBO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODEMBO
Provider First Name:
GEORGE
Provider Middle Name:
Provider Name Prefix Text:
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:
1982937967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
213 PATTON DRIVE, SUITE C.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELBY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28150-4696
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-487-4440
Provider Business Mailing Address Fax Number:
704-487-1511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 PATTON DR STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28150-4674
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-487-4440
Provider Business Practice Location Address Fax Number:
704-487-1511
Provider Enumeration Date:
09/09/2009

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: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 251C00000X . This is a "251C00000X TAXONOMY" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 251B00000X . This is a "251B00000X TAXONOMY" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 251S00000X . This is a "251S00000X TAXONOMY" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1255640165 . This is a "NPPES NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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