=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417378407
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAT SOBER LIVING LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2013
-----------------------------------------------------
Last Update Date | 12/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1420 SW 7TH TER
-----------------------------------------------------
City | DEERFIELD BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33441-6447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-213-4282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1660 SW 8TH AVE
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33486-6923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-213-4292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-FOUNDER
-----------------------------------------------------
Name | MR. KENNETH DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-213-4292
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 10D2069693
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------