Healthcare Provider Details

I. General information

NPI: 1285286476
Provider Name (Legal Business Name): ODYSSEY HOUSE LOUISIANA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4012 AVENUE H
LAKE CHARLES LA
70615-5186
US

IV. Provider business mailing address

1125 N TONTI ST
NEW ORLEANS LA
70119-3598
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-3786
  • Fax: 504-267-8571
Mailing address:
  • Phone: 504-821-9211
  • Fax: 504-267-8571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: AMBERZETTE K MULKEY
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 504-220-8058