Healthcare Provider Details

I. General information

NPI: 1790352367
Provider Name (Legal Business Name): ODYSSEY HOUSE LOUISIANA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 S BROAD ST STE A
NEW ORLEANS LA
70125-1953
US

IV. Provider business mailing address

PO BOX 19576
NEW ORLEANS LA
70179-0576
US

V. Phone/Fax

Practice location:
  • Phone: 504-384-2687
  • Fax: 504-269-3522
Mailing address:
  • Phone: 504-384-2687
  • Fax: 504-269-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: AMY BRIGGS BOSWORTH
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 504-821-9211