Provider Demographics
NPI:1114269313
Name:ODLAND FAMILY PRACTICE CLINIC, LLC
Entity Type:Organization
Organization Name:ODLAND FAMILY PRACTICE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDERGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:CMRS
Authorized Official - Phone:907-355-0850
Mailing Address - Street 1:950 E BOGARD RD
Mailing Address - Street 2:SUITE 234
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9481
Mailing Address - Country:US
Mailing Address - Phone:907-355-0850
Mailing Address - Fax:907-373-0117
Practice Address - Street 1:950 E BOGARD RD
Practice Address - Street 2:SUITE 234
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7184
Practice Address - Country:US
Practice Address - Phone:907-355-0850
Practice Address - Fax:907-373-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK955730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1574Medicaid
AKMD9857Medicaid
AKMD9857Medicaid
AKMD1574Medicaid