Basic Information
| Provider Information | |||||||||
| NPI: | 1679132179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODYSSEY HOUSE LOUISIANA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 N TONTI ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701193598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048219211 | ||||||||
| FaxNumber: | 5042678571 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 S. BROAD ST | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5078219211 | ||||||||
| FaxNumber: | 5042678571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2019 | ||||||||
| LastUpdateDate: | 06/08/2019 | ||||||||
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| AuthorizedOfficialLastName: | MULKEY | ||||||||
| AuthorizedOfficialFirstName: | AMBERZETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXEC. ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5048219211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.