MEDICARE: ABC SOBER LIVING

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	324500000X	Substance Abuse Rehabilitation Facility	370116AP	CA

General Provider Information

NPI Number	:	1881963932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABC SOBER LIVING

Provider Business Mailing Address
First Line	:	810 EMERALD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-2712
Country	:	US
Telephone Number	:	619-925-1879
Fax Number	:	858-274-8700

Provider Business Practice Location Address
First Line	:	810 EMERALD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-2712
Country	:	US
Telephone Number	:	619-925-1879
Fax Number	:	858-274-8700

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	DAVID POWERS
Credential	:
Telephone Number	:	619-925-1879

Provider Enumeration Date	:	12/19/2011
Last Update Date	:	12/19/2011

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Directions to “ABC SOBER LIVING ” Practice Location

Language	Start Address	Practice Location

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