=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457067670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANCTUARY SOBER LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2023
-----------------------------------------------------
Last Update Date | 01/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11645 N CAVE CREEK RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85020-1300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-612-3816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9952
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85068-0952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | JOSEPH LANDIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-309-9945
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------