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General NPI Number Information
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NPI Number | 1114269313
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Entity Type | Organization
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Legal Business Name | ODLAND FAMILY PRACTICE CLINIC, LLC
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Dates
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Enumeration Date | 03/26/2013
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Last Update Date | 03/26/2013
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Provider Practice Location Address
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Address Line | 950 E BOGARD RD SUITE 234
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City | WASILLA
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State | AK
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Zip | 99654-7184
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Country | US
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Telephone | 907-355-0850
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Fax | 907-373-0117
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Provider Business Mailing Address
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Address Line | 950 E BOGARD RD SUITE 234
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City | WASILLA
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State | AK
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Zip | 99687-9481
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Country | US
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Telephone | 907-355-0850
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Fax | 907-373-0117
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | SHANNON PENDERGRASS
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Credential | CMRS
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Telephone | 907-355-0850
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 955730
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License Number State | AK
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