Healthcare Provider Details

I. General information

NPI: 1528394418
Provider Name (Legal Business Name): SOBER LIFE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 SANTA MONICA BLVD SUITE 218
LOS ANGELES CA
90029-1252
US

IV. Provider business mailing address

5250 SANTA MONICA BLVD SUITE 218
LOS ANGELES CA
90029-1252
US

V. Phone/Fax

Practice location:
  • Phone: 323-465-3777
  • Fax: 323-465-3773
Mailing address:
  • Phone: 323-913-0212
  • Fax: 323-913-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANTRANIK KESHISHIAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 323-913-0212