Healthcare Provider Details

I. General information

NPI: 1326491283
Provider Name (Legal Business Name): SOBA MESA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 E ARBOR AVE
MESA AZ
85206-6064
US

IV. Provider business mailing address

6262 E BROADWAY RD STE 110
MESA AZ
85206-6101
US

V. Phone/Fax

Practice location:
  • Phone: 480-664-4053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberIFBH7657
License Number StateAZ

VIII. Authorized Official

Name: AUDREY GRAHAM
Title or Position: CFO
Credential:
Phone: 310-457-5250