MEDICARE: SOBRIETY SERVICES, INC.

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	320800000X	Mental Illness Community Based Residential Treatment Facility	30077AP	CA
2	324500000X	Substance Abuse Rehabilitation Facility	300177AP	CA

General Provider Information

NPI Number	:	1639359086
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOBRIETY SERVICES, INC.

Provider Business Mailing Address
First Line	:	31877 DEL OBISPO ST
Second Line	:	SUITE 105
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3233
Country	:	US
Telephone Number	:	949-273-4200
Fax Number	:	949-488-0447

Provider Business Practice Location Address
First Line	:	31877 DEL OBISPO ST
Second Line	:	SUITE 104
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3233
Country	:	US
Telephone Number	:	949-273-4200
Fax Number	:	949-489-1189

Authorized Official
Title or Position	:	CEO
Name	:	MR. DENNIS LARKIN
Credential	:	CATC
Telephone Number	:	949-273-4200

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	07/15/2008

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