Healthcare Provider Details

I. General information

NPI: 1639567845
Provider Name (Legal Business Name): SOBER PARTNERS BEACH HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 ALABAMA ST
HUNTINGTON BEACH CA
92648-5265
US

IV. Provider business mailing address

3419 VIA LIDO SUITE 241
NEWPORT BEACH CA
92663-3908
US

V. Phone/Fax

Practice location:
  • Phone: 949-201-5192
  • Fax: 928-708-9620
Mailing address:
  • Phone: 949-201-5192
  • Fax: 928-708-9620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number300305AP
License Number StateCA

VIII. Authorized Official

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