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General NPI Number Information
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NPI Number | 1275349375
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Entity Type | Organization
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Legal Business Name | IMMANUEL SOBRIETY INC.
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Dates
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Enumeration Date | 12/04/2024
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Last Update Date | 12/04/2024
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Provider Practice Location Address
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Address Line | 20170 WINTON ST
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City | CORONA
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State | CA
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Zip | 92881-4590
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Country | US
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Telephone | 951-200-4504
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10271
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City | MORENO VALLEY
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State | CA
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Zip | 92552-0271
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Country | US
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Telephone | 951-653-3000
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ELIZABETH REID
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Credential |
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Telephone | 951-530-7680
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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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