MEDICARE: SOZO RECOVERY RESIDENCE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QR0800X	Recovery Care Clinic/Center
3	251E00000X	Home Health Agency
4	172V00000X	Community Health Worker
5	177F00000X	Lodging Provider
6	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1265314157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOZO RECOVERY RESIDENCE

Provider Business Mailing Address
First Line	:	2768 N. GENEVIEVE ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92405
Country	:	US
Telephone Number	:	951-836-1253
Fax Number	:

Provider Business Practice Location Address
First Line	:	2768 N. GENEVIEVE ST
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92405-3516
Country	:	US
Telephone Number	:	951-835-1253
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JEANNA NICOLE MARQUECHO SHAW
Credential	:
Telephone Number	:	951-836-1253

Provider Enumeration Date	:	07/22/2025
Last Update Date	:	07/22/2025

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Directions to “SOZO RECOVERY RESIDENCE ” Practice Location

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