Provider Demographics
NPI:1356797294
Name:ODYSSEY HOUSE OF UTAH, INC.
Entity type:Organization
Organization Name:ODYSSEY HOUSE OF UTAH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PILCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-428-3407
Mailing Address - Street 1:344 E 100 S
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1700
Mailing Address - Country:US
Mailing Address - Phone:801-428-3407
Mailing Address - Fax:
Practice Address - Street 1:500 N RAINBOW BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1082
Practice Address - Country:US
Practice Address - Phone:801-428-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV2015688985251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000058171Medicare PIN