MEDICARE: ODYSSEY CHARTER SCHOOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)	1348	ID

General Provider Information

NPI Number	:	1861829731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODYSSEY CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	1235 JONES ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-6044
Country	:	US
Telephone Number	:	208-557-3627
Fax Number	:	208-522-1289

Provider Business Practice Location Address
First Line	:	1235 JONES ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-6044
Country	:	US
Telephone Number	:	208-557-3627
Fax Number	:	208-522-1289

Authorized Official
Title or Position	:	PRINCIPLE
Name	:	KARL PETERSON
Credential	:
Telephone Number	:	208-557-3627

Provider Enumeration Date	:	10/08/2013
Last Update Date	:	10/08/2013

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Directions to “ODYSSEY CHARTER SCHOOL ” Practice Location

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