Provider Demographics
NPI:1679132179
Name:ODYSSEY HOUSE LOUISIANA, INC
Entity Type:Organization
Organization Name:ODYSSEY HOUSE LOUISIANA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMBERZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MULKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-821-9211
Mailing Address - Street 1:1125 N TONTI ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3598
Mailing Address - Country:US
Mailing Address - Phone:504-821-9211
Mailing Address - Fax:504-267-8571
Practice Address - Street 1:2700 S. BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125
Practice Address - Country:US
Practice Address - Phone:507-821-9211
Practice Address - Fax:504-267-8571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-08
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)