Healthcare Provider Details

I. General information

NPI: 1154137321
Provider Name (Legal Business Name): SOBRAS RESTAURANT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 SW 98TH ST UNIT D1
SEATTLE WA
98106-2865
US

IV. Provider business mailing address

4228 249TH CT SE
SAMMAMISH WA
98029-5792
US

V. Phone/Fax

Practice location:
  • Phone: 206-915-8255
  • Fax:
Mailing address:
  • Phone: 206-915-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: EDA V MARTIN
Title or Position: CEO
Credential: RDN
Phone: 310-308-4463