MEDICARE: ODYSSEY HOUSE, LA INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	BH0003509	LA

General Provider Information

NPI Number	:	1265880686
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODYSSEY HOUSE, LA INC.

Provider Business Mailing Address
First Line	:	1125 N TONTI ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-3549
Country	:	US
Telephone Number	:	504-821-9211
Fax Number	:

Provider Business Practice Location Address
First Line	:	1138 N DUPRE ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70119-3204
Country	:	US
Telephone Number	:	504-821-9211
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	EDWARD CARLSON
Credential	:
Telephone Number	:	504-494-9628

Provider Enumeration Date	:	05/26/2016
Last Update Date	:	10/26/2016

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