Active NPI
Russ Odom, CMT, CMMP
- Massage Therapist
- San Diego, CA
National Provider Identifier
1104172253
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- 30211
- Practice address
- 2128 Crenshaw St
San Diego, CA 92105-5130 - Phone
- (619) 339-1306
- NPI assigned
- Jul 26, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | 30211 | CA | Primary |
Addresses
Primary practice location
2128 Crenshaw St
San Diego, CA 92105-5130
Mailing address
2128 Crenshaw St
San Diego, CA 92105-5130
Phone (619) 339-1306
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 30211 | CA | MD | Marriage & Family Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1343260800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1343260800000",
"number": "1104172253",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2128 CRENSHAW ST",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921055130",
"telephone_number": "619-339-1306"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2128 CRENSHAW ST",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "921055130",
"telephone_number": "619-339-1306"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ODOM",
"first_name": "RUSS",
"credential": "CMT, CMMP",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-07-26",
"last_updated": "2012-07-26",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "CA",
"license": "30211",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Diego, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 26, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.