Healthcare Provider Details

I. General information

NPI: 1932511698
Provider Name (Legal Business Name): FREEDOM HOUSE SOBER LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2014
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3852 PALOS VERDES ST SUITE 40
LAS VEGAS NV
89119-6909
US

IV. Provider business mailing address

3852 PALOS VERDES ST SUITE 40
LAS VEGAS NV
89119-6909
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-1300
  • Fax: 702-485-1210
Mailing address:
  • Phone: 702-485-1300
  • Fax: 702-485-1210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number324500000X
License Number StateNV

VIII. Authorized Official

Name: MR. JEFFREY BRIAN IVERSON
Title or Position: CEO
Credential:
Phone: 702-279-1298