Healthcare Provider Details

I. General information

NPI: 1336599182
Provider Name (Legal Business Name): SOBA TEXAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 DEZARAE, LOT 4
SAN ANTONIO TX
78253
US

IV. Provider business mailing address

1401 DEZARAE LOT 3
SAN ANTONIO TX
78253-5840
US

V. Phone/Fax

Practice location:
  • Phone: 210-530-4167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUDREY GRAHAM
Title or Position: CFO
Credential:
Phone: 310-457-5250