MEDICARE: SOUL PURPOSE SOBER LIVING LLC

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	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NV20171125758	OTHER		BUSINESS LICENSE

General Provider Information

NPI Number	:	1407310279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUL PURPOSE SOBER LIVING LLC

Provider Business Mailing Address
First Line	:	3667 EL CAMINO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-1102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3667 EL CAMINO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-1102
Country	:	US
Telephone Number	:	702-488-4918
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT DITOMASO
Credential	:
Telephone Number	:	702-488-4918

Provider Enumeration Date	:	01/25/2019
Last Update Date	:	02/07/2019

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