Basic Information
| Provider Information | |||||||||
| NPI: | 1245364645 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODYSSEY PROGRAMS LLC | ||||||||
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| OtherOrganizationName: | ODYSSEY - EAGAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN STREET | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267600 | ||||||||
| FaxNumber: | 6516313231 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 EAGAN INDUSTRIAL ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129164873 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | LINDEMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR - REVENUE CYCLE MGMT | ||||||||
| AuthorizedOfficialTelephone: | 6123267566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 324500000X | 8309164CDT | MN | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.