Healthcare Provider Details

I. General information

NPI: 1174236897
Provider Name (Legal Business Name): SANCTUARY SOBER LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17632 N 28TH ST
PHOENIX AZ
85032-1904
US

IV. Provider business mailing address

11645 N CAVE CREEK RD
PHOENIX AZ
85020-1300
US

V. Phone/Fax

Practice location:
  • Phone: 602-612-3816
  • Fax: 602-612-3769
Mailing address:
  • Phone: 602-612-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH LANDIN
Title or Position: CEO
Credential:
Phone: 480-309-9945