Healthcare Provider Details

I. General information

NPI: 1629788559
Provider Name (Legal Business Name): SOBER LIVING LIFESTYLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6013 W CLAREMONT ST
GLENDALE AZ
85301-4407
US

IV. Provider business mailing address

8751 N 51ST AVE STE 108
GLENDALE AZ
85302-4943
US

V. Phone/Fax

Practice location:
  • Phone: 602-421-6661
  • Fax:
Mailing address:
  • Phone: 602-421-6661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: WELLENGTEN JENKINS
Title or Position: DIRECTOR
Credential:
Phone: 602-421-6661