Provider Demographics
NPI:1326358599
Name:ODYSSEY HOUSE
Entity Type:Organization
Organization Name:ODYSSEY HOUSE
Other - Org Name:ODYSSEY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUBSTANCE ABUSE COUNSLER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:OCHOA
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC-I
Authorized Official - Phone:801-699-5917
Mailing Address - Street 1:340 EAST 100 SOUTH
Mailing Address - Street 2:ODYSSEY HOUSE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111
Mailing Address - Country:US
Mailing Address - Phone:801-322-4257
Mailing Address - Fax:
Practice Address - Street 1:340 EAST 100 SOUTH
Practice Address - Street 2:ODYSSEY HOUSE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ODYSSEY HOUSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7763887-6004324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility