Provider Demographics
NPI:1265020523
Name:EASTERN AVENUE SOBER LIVING INC
Entity Type:Organization
Organization Name:EASTERN AVENUE SOBER LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRESSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:185-953-9410
Mailing Address - Street 1:113 MASTERSON STATION DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-8736
Mailing Address - Country:US
Mailing Address - Phone:859-539-4106
Mailing Address - Fax:
Practice Address - Street 1:208 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-1918
Practice Address - Country:US
Practice Address - Phone:754-226-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100698150Medicaid