Provider Demographics
NPI:1528787710
Name:EXODUS SOBER LIVING HOME
Entity type:Organization
Organization Name:EXODUS SOBER LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-651-6322
Mailing Address - Street 1:1730 EUCLID AVE # 859
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5415
Mailing Address - Country:US
Mailing Address - Phone:619-651-6322
Mailing Address - Fax:
Practice Address - Street 1:7625 NORTH AVE
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1629
Practice Address - Country:US
Practice Address - Phone:619-651-6322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility