# ODLAND FAMILY PRACTICE CLINIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114269313
- **Authorized official:** SHANNON PENDERGRASS CMRS (BILLING MANAGER)
- **Authorized official phone:** (907) 355-0850

## Contact information

- **Practice address:** 950 E BOGARD RD, SUITE 234, WASILLA, AK 99654-7184
- **Practice address phone:** (907) 355-0850
- **Practice address fax:** (907) 373-0117
- **Mailing address:** 950 E BOGARD RD, SUITE 234, WASILLA, AK 99687-9481
- **Mailing address phone:** (907) 355-0850
- **Mailing address fax:** (907) 373-0117

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 955730 | AK | Yes |

## Other

- **Enumeration date:** 03/26/2013
- **Last updated:** 03/26/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | MD1574 | — | AK |
| 05 | — | MD9857 | — | AK |