| Odyssey Family Practice Llc | |
|
11595 Kenai Spur Highway Kenai AK 99611 | |
| (907) 313-4569 | |
| (907) 313-4939 |
| Full Name | Odyssey Family Practice Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 11595 Kenai Spur Highway, Kenai, Alaska |
| Authorized Official Name and Position | Jared Lee Wallace (OWNER) |
| Authorized Official Contact | 9073134569 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Odyssey Family Practice Llc Po Box 922 Kasilof AK 99610-0922 Ph: () - | Odyssey Family Practice Llc 11595 Kenai Spur Highway Kenai AK 99611 Ph: (907) 313-4569 |
| NPI Number | 1780142042 |
|---|---|
| Provider Enumeration Date | 03/06/2019 |
| Last Update Date | 02/05/2020 |
| Medicare PECOS PAC ID | 3476989062 |
|---|---|
| Medicare Enrollment ID | O20200129002758 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780142042 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| 261QX0100X | Clinic/center - Occupational Medicine | (* (Not Available)) | Secondary |
| Provider Name | Timothy W Miller |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1326275082 PECOS PAC ID: 3274787932 Enrollment ID: I20140102001615 |
| Provider Name | Virginia M Avila-haskell |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1982681151 PECOS PAC ID: 5496769655 Enrollment ID: I20140506000795 |
| Provider Name | Rachel Elizabeth Rekow |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1659996049 PECOS PAC ID: 6103243712 Enrollment ID: I20200819001486 |
| Provider Name | Heather Nancy Moon |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1205547205 PECOS PAC ID: 0244601391 Enrollment ID: I20230127000777 |
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