Provider Demographics
NPI:1538805239
Name:ODIN HEALTHCARE PLLC
Entity type:Organization
Organization Name:ODIN HEALTHCARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:813-817-1135
Mailing Address - Street 1:3151 DALLAS HIGH SHOALS HWY UNIT 935
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-1369
Mailing Address - Country:US
Mailing Address - Phone:803-470-5358
Mailing Address - Fax:
Practice Address - Street 1:3151 DALLAS HIGH SHOALS HWY UNIT 935
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1369
Practice Address - Country:US
Practice Address - Phone:803-470-5358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty