Provider Demographics
NPI:1255813655
Name:O'BIES ADOBE, LLC
Entity type:Organization
Organization Name:O'BIES ADOBE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:O'BRYAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:907-244-6929
Mailing Address - Street 1:4128 E COUNTRY FIELD CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-6665
Mailing Address - Country:US
Mailing Address - Phone:907-244-6929
Mailing Address - Fax:
Practice Address - Street 1:1790 N CENTURIAN PL APT 3
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-5470
Practice Address - Country:US
Practice Address - Phone:907-244-6929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10078143320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities