Healthcare Provider Details

I. General information

NPI: 1629421037
Provider Name (Legal Business Name): SOBER SPOT LLC, THE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25241 PASEO DE ALICIA
LAGUNA HILLS CA
92653-4643
US

IV. Provider business mailing address

25241 PASEO DE ALICIA
LAGUNA HILLS CA
92653-4643
US

V. Phone/Fax

Practice location:
  • Phone: 949-388-5123
  • Fax: 888-510-9071
Mailing address:
  • Phone: 949-388-5123
  • Fax: 888-510-9071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number300333AP
License Number StateCA

VIII. Authorized Official

Name: ALAN BALAGUL
Title or Position: FOUNDER
Credential: PROGRM DIRECTOR
Phone: 718-614-8044