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General NPI Number Information
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NPI Number | 1366764045
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Entity Type | Organization
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Legal Business Name | CLEAN ADVENTURES OF SOBER LIVING, LLC
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Dates
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Enumeration Date | 02/22/2010
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Last Update Date | 04/21/2016
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Provider Practice Location Address
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Address Line | 534 MADISON AVE
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City | PRESCOTT
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State | AZ
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Zip | 86301-2433
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Country | US
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Telephone | 928-443-8767
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Fax | 928-776-4781
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Provider Business Mailing Address
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Address Line | 534 MADISON AVE
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City | PRESCOTT
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State | AZ
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Zip | 86301-2433
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Country | US
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Telephone | 928-443-8767
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Fax | 928-776-4781
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Authorized Official
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Title or Position | OWNER/EXECUTIVE DIRECTOR
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Name | ROBERT CARSON PATTON
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Credential |
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Telephone | 928-443-8767
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | BH-3525
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | OTC6727
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License Number State | AZ
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