Provider Demographics
NPI:1548567001
Name:ODYSSEY HOUSE INC LOUISIANA
Entity Type:Organization
Organization Name:ODYSSEY HOUSE INC LOUISIANA
Other - Org Name:ODYSSEY HOUSE COMMUNITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DE MONREDON
Authorized Official - Suffix:
Authorized Official - Credentials:C-ANP
Authorized Official - Phone:504-378-7816
Mailing Address - Street 1:1125 N TONTI ST
Mailing Address - Street 2:MEDICAL CLINIC
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3549
Mailing Address - Country:US
Mailing Address - Phone:504-378-7816
Mailing Address - Fax:
Practice Address - Street 1:1125 N TONTI ST
Practice Address - Street 2:MEDICAL CLINIC
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-3549
Practice Address - Country:US
Practice Address - Phone:504-378-7816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center