=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033041579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOVEREIGN WELLNESS & STABILIZATION RESIDENCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2026
-----------------------------------------------------
Last Update Date | 06/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4940 E FORT KING ST
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34470-1504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-207-3170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 770131
-----------------------------------------------------
City | OCALA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34477-0131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-207-3170
-----------------------------------------------------
Fax | 352-207-3170
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER/TREASURER
-----------------------------------------------------
Name | MR. COURTNEY PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-207-3170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------