Healthcare Provider Details

I. General information

NPI: 1952050957
Provider Name (Legal Business Name): ODESSA CAPITAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 08/29/2022
Certification Date: 08/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 LITTLE RD STE 103
TRINITY FL
34655-1815
US

IV. Provider business mailing address

3633 LITTLE RD STE 103
TRINITY FL
34655-1815
US

V. Phone/Fax

Practice location:
  • Phone: 352-293-2810
  • Fax: 727-264-2117
Mailing address:
  • Phone: 727-633-0003
  • Fax: 727-334-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRANDON WOMACK
Title or Position: MANAGING PARTNER
Credential:
Phone: 352-293-2810