Provider Demographics
NPI:1760732002
Name:SONOMA RECOVERY SERVICES, LLC
Entity Type:Organization
Organization Name:SONOMA RECOVERY SERVICES, LLC
Other - Org Name:OLYMPIA HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING MEMBER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:THURSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-795-7609
Mailing Address - Street 1:11207 VALLEY FORD RD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3700
Mailing Address - Country:US
Mailing Address - Phone:707-795-7609
Mailing Address - Fax:
Practice Address - Street 1:11207 VALLEY FORD RD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3700
Practice Address - Country:US
Practice Address - Phone:707-795-7609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility