NPIMap

Organization Active NPI

Odyssey House Louisiana, Inc

  • Federally Qualified Health Center (FQHC)
  • New Orleans, LA
National Provider Identifier
1679132179
Registry record updated Jun 8, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
ODYSSEY HOUSE LOUISIANA, INC
Practice address
2700 S. Broad St
New Orleans, LA 70125
Phone
(507) 821-9211
Fax
(504) 267-8571
NPI assigned
Jun 8, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 8, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amberzette Mulkey
Title
Exec. Assistant
Phone
(504) 821-9211

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

2700 S. Broad St
New Orleans, LA 70125

Mailing address

1125 N Tonti St
New Orleans, LA 70119-3598
Phone (504) 821-9211

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220124001347 LA Part A Provider - Federally Qualified Health Center (FQHC) 5294917928 Practice locations: New Orleans, LA

Federally qualified health center certification: CCN 191091

Legal name
ODYSSEY HOUSE LOUISIANA, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 22, 2022
Last certification
Feb 22, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 21, 2021 in LA
Enrollment address
2700 S Broad St
New Orleans, LA 70125-1953

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Odyssey House Louisiana Inc14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mia Jefferson Individual Corporate Officer Jan 1, 2018
Amy Bosworth Individual Corporate OfficerChief Operating Officer Sep 1, 2021
Odyssey House Louisiana, Inc Organization, New Orleans, LA Corporation, Medical provider/supplier, Non-profit Operational/Managerial Control Jan 1, 2018
Edward Carlson Individual Corporate Director Jan 1, 2018
W-2 Managing Employee Jan 1, 2018

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Odyssey House Louisiana, IncNew Orleans, LA, CCN 191945 Federally qualified health center Operational/Managerial Control Mar 1, 2011

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1559952000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1559952000000",
    "number": "1679132179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1125 N TONTI ST",
            "city": "NEW ORLEANS",
            "state": "LA",
            "postal_code": "701193598",
            "telephone_number": "504-821-9211",
            "fax_number": "504-267-8571"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2700 S. BROAD ST",
            "city": "NEW ORLEANS",
            "state": "LA",
            "postal_code": "70125",
            "telephone_number": "507-821-9211",
            "fax_number": "504-267-8571"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ODYSSEY HOUSE LOUISIANA, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-06-08",
        "last_updated": "2019-06-08",
        "status": "A",
        "authorized_official_last_name": "MULKEY",
        "authorized_official_first_name": "AMBERZETTE",
        "authorized_official_title_or_position": "EXEC. ASSISTANT",
        "authorized_official_telephone_number": "504-821-9211"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in New Orleans, LA

Sources for this page

Verify at the official NPI Registry.