Healthcare Provider Details

I. General information

NPI: 1356051122
Provider Name (Legal Business Name): SOBER MOUNTAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2022
Last Update Date: 01/19/2026
Certification Date: 01/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 E OLD LINDEN RD STE 3
SHOW LOW AZ
85901-4817
US

IV. Provider business mailing address

580 E OLD LINDEN RD STE 7
SHOW LOW AZ
85901-4817
US

V. Phone/Fax

Practice location:
  • Phone: 928-551-6099
  • Fax:
Mailing address:
  • Phone: 928-551-6099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: AMMON D MANGUM
Title or Position: OWNER/ PARTNER
Credential:
Phone: 928-551-6099