# ODOM SPORTS MEDICINE, P.A.

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** ODOM SPORTS MEDICINE, P.A.
- **Other names:** Odom Health and Wellness
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1740625870
- **Legal business name:** ODOM SPORTS MEDICINE, P.A.
- **Authorized official:** DR. JOHN H.L. ODOM JR. M.D. (PRESIDENT)
- **Authorized official phone:** (952) 224-1919

## Contact information

- **Practice address:** 500 S CHERRY ST, WACONIA, MN 55387-4515
- **Practice address phone:** (952) 856-4722
- **Mailing address:** 10500 WAYZATA BLVD, MINNETONKA, MN 55305-1511
- **Mailing address phone:** (952) 224-1919

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | NULL | Yes |
| 207QS0010X | Sports Medicine (Family Medicine) Physician | — | — | Yes |
| 225100000X | Physical Therapist | — | NULL | — |
| 225100000X | Physical Therapist | — | — | — |
| 225X00000X | Occupational Therapist | — | NULL | — |
| 225X00000X | Occupational Therapist | — | — | — |

## Other

- **Enumeration date:** 05/02/2013
- **Last updated:** 05/02/2013