Provider Demographics
NPI:1780142042
Name:ODYSSEY FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:ODYSSEY FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:907-313-4569
Mailing Address - Street 1:PO BOX 922
Mailing Address - Street 2:
Mailing Address - City:KASILOF
Mailing Address - State:AK
Mailing Address - Zip Code:99610-0922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11595 KENAI SPUR HIGHWAY
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611
Practice Address - Country:US
Practice Address - Phone:907-313-4569
Practice Address - Fax:907-313-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Single Specialty