Healthcare Provider Details

I. General information

NPI: 1932320256
Provider Name (Legal Business Name): ODYSSEY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4832 LINCOLN BLVD
MARINA DEL REY CA
90292-6917
US

IV. Provider business mailing address

4832 LINCOLN BLVD
MARINA DEL REY CA
90292-6917
US

V. Phone/Fax

Practice location:
  • Phone: 310-821-7658
  • Fax: 310-821-1708
Mailing address:
  • Phone: 310-821-7658
  • Fax: 310-821-1708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE4238
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC35069
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA96388
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG79180
License Number StateCA

VIII. Authorized Official

Name: DR. MARICA GLENN
Title or Position: OWNER
Credential: M.D
Phone: 310-821-7658