=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134095540
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRAMENTO OUTPATIENT RECOVERY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 47TH AVE STE 106
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95824-3923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-415-3411
-----------------------------------------------------
Fax | 916-415-3400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 47TH AVE STE 106
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95824-3923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-415-3411
-----------------------------------------------------
Fax | 916-415-3400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/CEO
-----------------------------------------------------
Name | MS. TANISHA CARAVEO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-415-3411
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------