Provider Demographics
NPI:1477983393
Name:SOBA OUTPATIENT AND RECOVERY LLC
Entity Type:Organization
Organization Name:SOBA OUTPATIENT AND RECOVERY LLC
Other - Org Name:SOAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HANNLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RRW
Authorized Official - Phone:310-924-2053
Mailing Address - Street 1:22669 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-5036
Mailing Address - Country:US
Mailing Address - Phone:310-774-0904
Mailing Address - Fax:310-919-3667
Practice Address - Street 1:22814 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-5041
Practice Address - Country:US
Practice Address - Phone:310-310-7740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOBA OUTPATIENT AND RECOVERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health