Healthcare Provider Details

I. General information

NPI: 1780187054
Provider Name (Legal Business Name): BRIAN JORDAN SOBOCINSKI RADT-1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2986 COLOMA ST
PLACERVILLE CA
95667-4441
US

IV. Provider business mailing address

838 BEACH CT.
LOTUS CA
95651-4441
US

V. Phone/Fax

Practice location:
  • Phone: 530-748-3706
  • Fax:
Mailing address:
  • Phone: 530-626-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCI27210419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: