MEDICARE: ODYSSEY FAMILY PRACTICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QX0100X	Occupational Medicine Clinic/Center
2	291U00000X	Clinical Medical Laboratory
3	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1780142042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODYSSEY FAMILY PRACTICE

Provider Business Mailing Address
First Line	:	PO BOX 922
Second Line	:
City	:	KASILOF
State	:	AK
Zip	:	99610-0922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11595 KENAI SPUR HIGHWAY
Second Line	:
City	:	KENAI
State	:	AK
Zip	:	99611
Country	:	US
Telephone Number	:	907-313-4569
Fax Number	:	907-313-4939

Authorized Official
Title or Position	:	OWNER
Name	:	JARED LEE WALLACE
Credential	:	PA-C
Telephone Number	:	907-313-4569

Provider Enumeration Date	:	03/06/2019
Last Update Date	:	12/01/2025

Similar Medicare Providers

1740001122 — AMANDA EBEN
Practice Location Address:

508 UPLAND ST
KENAI, AK
99611-8026

Practice Phone: 907-335-7500
Practice Fax:

1649798661 — DR. KATHERINE ANN BUTLER PHARMD, RPH
Practice Location Address:

10575 KENAI-SPUR HWY
KENAI, AK
99611

Practice Phone: 907-335-2061
Practice Fax:

1831052513 — DELEN MANAL NISAN BYRD
Practice Location Address:

508 UPLAND ST
KENAI, AK
99611-8026

Practice Phone: 907-335-7500
Practice Fax:

1386655421 — THREE BEARS ALASKA, INC
Practice Location Address:

10575 KENAI SPUR HWY
KENAI, AK
99611-7812

Practice Phone: 907-335-2061
Practice Fax: 907-335-2062

1619979184 — CITY OF KENAI
Practice Location Address:

210 FIDALGO AVE
KENAI, AK
99611-7750

Practice Phone: 907-283-8228
Practice Fax:

1346116852 — LAURA BUTLER
Practice Location Address:

508 UPLAND ST
KENAI, AK
99611-8026

Practice Phone: 907-335-7500
Practice Fax:

Directions to “ODYSSEY FAMILY PRACTICE ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2025 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.