Healthcare Provider Details

I. General information

NPI: 1265871644
Provider Name (Legal Business Name): ODYSSEY HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E 100 S
SALT LAKE CITY UT
84111-1700
US

IV. Provider business mailing address

344 E 100 S SUITE 301
SALT LAKE CITY UT
84111-1700
US

V. Phone/Fax

Practice location:
  • Phone: 928-708-9615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW LUCHINI
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 928-533-4220