Healthcare Provider Details

I. General information

NPI: 1265314157
Provider Name (Legal Business Name): SOZO RECOVERY RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2768 N. GENEVIEVE ST
SAN BERNARDINO CA
92405-3516
US

IV. Provider business mailing address

2768 N. GENEVIEVE ST
SAN BERNARDINO CA
92405
US

V. Phone/Fax

Practice location:
  • Phone: 951-835-1253
  • Fax:
Mailing address:
  • Phone: 951-836-1253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: JEANNA NICOLE MARQUECHO SHAW
Title or Position: DIRECTOR
Credential:
Phone: 951-836-1253