Provider Demographics
NPI:1629788559
Name:SOBER LIVING LIFESTYLE
Entity Type:Organization
Organization Name:SOBER LIVING LIFESTYLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WELLENGTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-421-6661
Mailing Address - Street 1:8751 N 51ST AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-4943
Mailing Address - Country:US
Mailing Address - Phone:602-421-6661
Mailing Address - Fax:
Practice Address - Street 1:6013 W CLAREMONT ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-4407
Practice Address - Country:US
Practice Address - Phone:602-421-6661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No177F00000XOther Service ProvidersLodging
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness