Provider Demographics
NPI:1366866907
Name:WEST SIDE SOBER LIVING
Entity Type:Organization
Organization Name:WEST SIDE SOBER LIVING
Other - Org Name:DBA ONE TWELVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-513-7475
Mailing Address - Street 1:12218 LAKE STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5172
Mailing Address - Country:US
Mailing Address - Phone:952-513-7475
Mailing Address - Fax:
Practice Address - Street 1:12218 LAKE STREET EXT
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-5172
Practice Address - Country:US
Practice Address - Phone:952-513-7475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1066522324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility