Individual
COLE SHANE ODOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3420 S. FORK AVE, NAMPA, ID 83686
(208) 250-7733
Mailing address
3420 S FORK AVE, NAMPA, ID 83686-4856
(970) 589-5060
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
347C00000X
Private Vehicle
—
—
Other
Enumeration date
07/30/2025
Last updated
07/30/2025
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