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General NPI Number Information
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NPI Number | 1629788559
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Entity Type | Organization
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Legal Business Name | SOBER LIVING LIFESTYLE
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Dates
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Enumeration Date | 12/01/2022
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Last Update Date | 12/01/2022
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Provider Practice Location Address
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Address Line | 6013 W CLAREMONT ST
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City | GLENDALE
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State | AZ
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Zip | 85301-4407
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Country | US
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Telephone | 602-421-6661
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Fax |
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Provider Business Mailing Address
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Address Line | 8751 N 51ST AVE STE 108
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City | GLENDALE
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State | AZ
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Zip | 85302-4943
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Country | US
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Telephone | 602-421-6661
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | WELLENGTEN JENKINS
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Credential |
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Telephone | 602-421-6661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 177F00000X
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Taxonomy Name | Lodging Provider
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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