Provider Demographics
NPI:1932578408
Name:ODYSSEY HOUSE LOUISIANA INC
Entity Type:Organization
Organization Name:ODYSSEY HOUSE LOUISIANA INC
Other - Org Name:ODYSSEY HOUSE COMMUNITY MEDICAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-383-8559
Mailing Address - Street 1:1125 N TONTI ST
Mailing Address - Street 2:C/O COMMUNITY CLINIC
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-3549
Mailing Address - Country:US
Mailing Address - Phone:504-383-8559
Mailing Address - Fax:
Practice Address - Street 1:1125 N. TONTI ST.
Practice Address - Street 2:C/O COMMUNITY MEDICAL CLINIC
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119
Practice Address - Country:US
Practice Address - Phone:504-383-8559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)