Basic Information
Provider Information
NPI: 1740317544
EntityType: 2
ReplacementNPI:  
OrganizationName: LINCOLN COUNTY PUBLIC HOSPITAL DISTRICT 1
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: ODESSA CLINIC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 190
Address2:  
City: ODESSA
State: WA
PostalCode: 99159
CountryCode: US
TelephoneNumber: 5099822611
FaxNumber: 5099822675
Practice Location
Address1: 510 E. AMENDE
Address2:  
City: ODESSA
State: WA
PostalCode: 99159
CountryCode: US
TelephoneNumber: 5099822611
FaxNumber: 5099822675
Other Information
ProviderEnumerationDate: 02/27/2007
LastUpdateDate: 04/20/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: SERLE
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 5099822611
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/20/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
701333705WA MEDICAID


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