Provider Demographics
NPI:1356761928
Name:WALNUT CREEK SOBER LIVING AND RECOVERY LLC
Entity type:Organization
Organization Name:WALNUT CREEK SOBER LIVING AND RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-604-0279
Mailing Address - Street 1:12410 TAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064-9365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3821 WALNUT CREEK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43224-2530
Practice Address - Country:US
Practice Address - Phone:740-604-0279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory