Provider Demographics
NPI:1629649132
Name:SANCTUARY SOBER LIVING LLC
Entity Type:Organization
Organization Name:SANCTUARY SOBER LIVING LLC
Other - Org Name:SRC CAVE CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDIN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:480-309-9945
Mailing Address - Street 1:PO BOX 9952
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-0952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11645 N CAVE CREEK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1300
Practice Address - Country:US
Practice Address - Phone:602-612-3816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANCTUARY SOBER LIVING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-06
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No174200000XOther Service ProvidersMealsGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ085186Medicaid