Healthcare Provider Details

I. General information

NPI: 1033908371
Provider Name (Legal Business Name): IMMANUEL SOBRIETY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4954 ARLINGTON AVE # A&B
RIVERSIDE CA
92504-2746
US

IV. Provider business mailing address

PO BOX 10271
MORENO VALLEY CA
92552-0271
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-3000
  • Fax:
Mailing address:
  • Phone: 951-653-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH REID
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 951-530-7680