MEDICARE: SOBA OUTPATIENT AND RECOVERY 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1477983393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOBA OUTPATIENT AND RECOVERY LLC

Provider Business Mailing Address
First Line	:	22669 PACIFIC COAST HWY
Second Line	:
City	:	MALIBU
State	:	CA
Zip	:	90265-5036
Country	:	US
Telephone Number	:	310-774-0904
Fax Number	:	310-919-3667

Provider Business Practice Location Address
First Line	:	22814 PACIFIC COAST HWY
Second Line	:
City	:	MALIBU
State	:	CA
Zip	:	90265-5041
Country	:	US
Telephone Number	:	310-310-7740
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GREGORY PAUL HANNLEY
Credential	:	RRW
Telephone Number	:	310-924-2053

Provider Enumeration Date	:	11/13/2013
Last Update Date	:	11/13/2013

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