Provider Demographics
NPI:1851136147
Name:ODUM, SAMUEL KEVIN (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KEVIN
Last Name:ODUM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MIRROR LAKE BLVD STE S
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-2126
Mailing Address - Country:US
Mailing Address - Phone:770-456-7877
Mailing Address - Fax:770-456-7880
Practice Address - Street 1:2983 CHAPEL HILL RD STE 106
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1767
Practice Address - Country:US
Practice Address - Phone:770-947-8177
Practice Address - Fax:770-947-8377
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist