Provider Demographics
NPI:1821971326
Name:ODOM, COLE SHANE
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:SHANE
Last Name:ODOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 S FORK AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-4856
Mailing Address - Country:US
Mailing Address - Phone:970-589-5060
Mailing Address - Fax:
Practice Address - Street 1:3420 S. FORK AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-250-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No347C00000XTransportation ServicesPrivate Vehicle