Healthcare Provider Details

I. General information

NPI: 1174490536
Provider Name (Legal Business Name): LEGACY SOBRIETY AND RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 W KILBOURN AVE APT 3
MILWAUKEE WI
53208-3501
US

IV. Provider business mailing address

2810 W KILBOURN AVE APT 3
MILWAUKEE WI
53208-3501
US

V. Phone/Fax

Practice location:
  • Phone: 414-309-3213
  • Fax: 414-309-3213
Mailing address:
  • Phone: 414-309-3213
  • Fax: 414-309-3213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DAVIDA CLIFTON
Title or Position: OWNER
Credential:
Phone: 414-309-3213