Provider Demographics
NPI:1699514711
Name:ODYSSEY ENTERPRISES LLC
Entity type:Organization
Organization Name:ODYSSEY ENTERPRISES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:PENTICUFF
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:317-349-7680
Mailing Address - Street 1:2559 S ADDISYN LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3269
Mailing Address - Country:US
Mailing Address - Phone:317-349-7680
Mailing Address - Fax:833-975-0724
Practice Address - Street 1:2559 S ADDISYN LN
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3269
Practice Address - Country:US
Practice Address - Phone:317-349-7680
Practice Address - Fax:833-975-0724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty