Healthcare Provider Details

I. General information

NPI: 1407481245
Provider Name (Legal Business Name): ODYSSEY HOUSE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 E 300 S
SALT LAKE CITY UT
84102
US

IV. Provider business mailing address

344 E 100 S STE 301
SALT LAKE CITY UT
84111-1727
US

V. Phone/Fax

Practice location:
  • Phone: 801-428-3500
  • Fax: 801-210-5031
Mailing address:
  • Phone: 801-322-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAM COHEN
Title or Position: CEO
Credential:
Phone: 801-428-3449