Basic Information
| Provider Information | |||||||||
| NPI: | 1679051759 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLINT ODYSSEY HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 529 MARTIN LUTHER KING BLVD | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102387226 | ||||||||
| FaxNumber: | 8102385518 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 GRISWOLD ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480605847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109375366 | ||||||||
| FaxNumber: | 8109375172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2018 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | HARPER-SHELTON | ||||||||
| AuthorizedOfficialFirstName: | ROCHELL | ||||||||
| AuthorizedOfficialMiddleName: | DENELL | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 8102387226 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLINT ODYSSEY HOUSE, INC. | ||||||||
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| AuthorizedOfficialCredential: | MSA | ||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.