MEDICARE: JONIK SOBER LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1366173254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JONIK SOBER LIVING LLC

Provider Business Mailing Address
First Line	:	7852 E BILLINGS ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-7548
Country	:	US
Telephone Number	:	480-519-4138
Fax Number	:

Provider Business Practice Location Address
First Line	:	7852 E BILLINGS ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85207-7548
Country	:	US
Telephone Number	:	480-519-4138
Fax Number	:

Authorized Official
Title or Position	:	OPERATING OFFICER
Name	:	MRS. NKIRUKA MIRIAM POLLYN
Credential	:
Telephone Number	:	480-519-4138

Provider Enumeration Date	:	06/21/2022
Last Update Date	:	06/21/2022

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Directions to “JONIK SOBER LIVING LLC ” Practice Location

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