Healthcare Provider Details

I. General information

NPI: 1699514711
Provider Name (Legal Business Name): ODYSSEY ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 S ADDISYN LN
BLOOMINGTON IN
47403-3269
US

IV. Provider business mailing address

2559 S ADDISYN LN
BLOOMINGTON IN
47403-3269
US

V. Phone/Fax

Practice location:
  • Phone: 317-349-7680
  • Fax: 833-975-0724
Mailing address:
  • Phone: 317-349-7680
  • Fax: 833-975-0724

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 Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES M PENTICUFF JR.
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 317-349-7680