Organization
ODLAND FAMILY PRACTICE CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHANNON PENDERGRASS CMRS (BILLING MANAGER)
(907) 355-0850
Entity
Organization
Contact information
Practice address
950 E BOGARD RD, SUITE 234, WASILLA, AK 99654-7184
(907) 355-0850
(907) 373-0117
Mailing address
950 E BOGARD RD, SUITE 234, WASILLA, AK 99687-9481
(907) 355-0850
(907) 373-0117
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
955730
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
MD1574
—
AK
05
—
MD9857
—
AK
Enumeration date
03/26/2013
Last updated
03/26/2013
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