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General NPI Number Information
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NPI Number | 1477943496
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Entity Type | Organization
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Legal Business Name | CLEAN & SOBER LIVING CORP
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Dates
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Enumeration Date | 01/29/2015
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Last Update Date | 01/29/2015
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Provider Practice Location Address
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Address Line | 260 VICTORIA ST APT C1
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City | COSTA MESA
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State | CA
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Zip | 92627-6002
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Country | US
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Telephone | 949-836-8779
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Fax |
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Provider Business Mailing Address
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Address Line | 23665 BIRTCHER DR
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City | LAKE FOREST
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State | CA
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Zip | 92630-1770
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Country | US
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Telephone | 949-278-2843
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | CHERYL GWARTNEY
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Credential |
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Telephone | 949-278-2843
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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