Healthcare Provider Details

I. General information

NPI: 1790133346
Provider Name (Legal Business Name): SOBER PARTNERS WATERFRONT RECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 17TH ST STE A
COSTA MESA CA
92627-4512
US

IV. Provider business mailing address

1001 W 17TH ST STE A
COSTA MESA CA
92627-4512
US

V. Phone/Fax

Practice location:
  • Phone: 949-201-5192
  • Fax:
Mailing address:
  • Phone: 949-201-5192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number200205BP
License Number StateCA

VIII. Authorized Official

Name: SCOTT RAFFA
Title or Position: CEO
Credential:
Phone: 949-201-5192