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General NPI Number Information
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NPI Number | 1265020523
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Entity Type | Organization
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Legal Business Name | EASTERN AVENUE SOBER LIVING INC
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Dates
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Enumeration Date | 01/04/2021
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Last Update Date | 12/10/2021
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Provider Practice Location Address
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Address Line | 208 EASTERN AVE
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City | LEXINGTON
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State | KY
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Zip | 40508-1918
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Country | US
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Telephone | 754-226-5343
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Fax |
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Provider Business Mailing Address
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Address Line | 113 MASTERSON STATION DR
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City | LEXINGTON
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State | KY
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Zip | 40511-8736
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Country | US
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Telephone | 859-539-4106
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Fax |
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Authorized Official
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Title or Position | BOARD PRESIDENT
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Name | MR. VERNON PRESSLEY
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Credential | ADMINISTRATOR
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Telephone | 185-953-9410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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