Healthcare Provider Details

I. General information

NPI: 1013633882
Provider Name (Legal Business Name): SOBER LIVING IN MADISON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N SHERMAN AVE
MADISON WI
53704-3932
US

IV. Provider business mailing address

2101 N SHERMAN AVE
MADISON WI
53704-3932
US

V. Phone/Fax

Practice location:
  • Phone: 608-520-7142
  • Fax:
Mailing address:
  • Phone: 608-520-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MIRZO KHASIMOV
Title or Position: PRESIDENT
Credential:
Phone: 608-520-7142