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General NPI Number Information
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NPI Number | 1780142042
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Entity Type | Organization
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Legal Business Name | ODYSSEY FAMILY PRACTICE
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Dates
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Enumeration Date | 03/06/2019
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 11595 KENAI SPUR HIGHWAY
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City | KENAI
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State | AK
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Zip | 99611
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Country | US
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Telephone | 907-313-4569
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Fax | 907-313-4939
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Provider Business Mailing Address
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Address Line | PO BOX 922
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City | KASILOF
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State | AK
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Zip | 99610-0922
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JARED LEE WALLACE
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Credential | PA-C
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Telephone | 907-313-4569
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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