Healthcare Provider Details

I. General information

NPI: 1780142042
Provider Name (Legal Business Name): ODYSSEY FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11595 KENAI SPUR HIGHWAY
KENAI AK
99611
US

IV. Provider business mailing address

PO BOX 922
KASILOF AK
99610-0922
US

V. Phone/Fax

Practice location:
  • Phone: 907-313-4569
  • Fax: 907-313-4939
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: JARED LEE WALLACE
Title or Position: OWNER
Credential: PA-C
Phone: 907-313-4569