Healthcare Provider Details

I. General information

NPI: 1033041579
Provider Name (Legal Business Name): SOVEREIGN WELLNESS & STABILIZATION RESIDENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 E FORT KING ST
OCALA FL
34470-1504
US

IV. Provider business mailing address

PO BOX 770131
OCALA FL
34477-0131
US

V. Phone/Fax

Practice location:
  • Phone: 352-207-3170
  • Fax:
Mailing address:
  • Phone: 352-207-3170
  • Fax: 352-207-3170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. COURTNEY PETERSON
Title or Position: CHIEF FINANCIAL OFFICER/TREASURER
Credential:
Phone: 352-207-3170