Provider Demographics
NPI:1700952678
Name:O'DELL, KEVIN JAMES (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:O'DELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28245 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2863
Mailing Address - Country:US
Mailing Address - Phone:248-552-1110
Mailing Address - Fax:248-552-0771
Practice Address - Street 1:28245 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2863
Practice Address - Country:US
Practice Address - Phone:248-552-1110
Practice Address - Fax:248-552-0771
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006957111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4691445Medicaid
MIP25790002Medicare PIN