Provider Demographics
NPI:1760160550
Name:SOBRIUS AT BEDFORD, LLC
Entity Type:Organization
Organization Name:SOBRIUS AT BEDFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-329-6687
Mailing Address - Street 1:506 CLIFFVIEW RD
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-5084
Mailing Address - Country:US
Mailing Address - Phone:276-601-2736
Mailing Address - Fax:276-618-7246
Practice Address - Street 1:4059 LOWRY RD
Practice Address - Street 2:
Practice Address - City:GOODE
Practice Address - State:VA
Practice Address - Zip Code:24556-2727
Practice Address - Country:US
Practice Address - Phone:276-601-2736
Practice Address - Fax:276-618-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility