Provider Demographics
NPI:1164618534
Name:EXXODUS FOUNDATION INC
Entity Type:Organization
Organization Name:EXXODUS FOUNDATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO., PRES., EXECUTIVE DIR., TRUST.
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS,MS,ESQ,
Authorized Official - Phone:504-392-0272
Mailing Address - Street 1:21 ENGLISH TURN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-3308
Mailing Address - Country:US
Mailing Address - Phone:504-392-0272
Mailing Address - Fax:504-392-0274
Practice Address - Street 1:21 ENGLISH TURN DR
Practice Address - Street 2:SUITE A
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70131-3308
Practice Address - Country:US
Practice Address - Phone:504-392-0272
Practice Address - Fax:504-392-0274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA0974029834320900000X
LALA9837472386320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LALA12345678Medicaid
LALA28176543Medicaid
LALA9488487737Medicaid
LALA2019837465Medicaid