Provider Demographics
NPI:1528200961
Name:SOBER SHORES, INCORPORATED
Entity type:Organization
Organization Name:SOBER SHORES, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:REAGAN
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:SR
Authorized Official - Credentials:JD, CAS
Authorized Official - Phone:866-660-5763
Mailing Address - Street 1:42509 CARINO PL
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-2239
Mailing Address - Country:US
Mailing Address - Phone:866-660-5763
Mailing Address - Fax:951-526-2264
Practice Address - Street 1:42509 CARINO PL
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-2239
Practice Address - Country:US
Practice Address - Phone:866-660-5763
Practice Address - Fax:951-526-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330084AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility