Healthcare Provider Details

I. General information

NPI: 1679132179
Provider Name (Legal Business Name): ODYSSEY HOUSE LOUISIANA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2019
Last Update Date: 06/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 S. BROAD ST
NEW ORLEANS LA
70125
US

IV. Provider business mailing address

1125 N TONTI ST
NEW ORLEANS LA
70119-3598
US

V. Phone/Fax

Practice location:
  • Phone: 507-821-9211
  • 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 Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: AMBERZETTE MULKEY
Title or Position: EXEC. ASSISTANT
Credential:
Phone: 504-821-9211