Provider Demographics
NPI:1780449306
Name:SUPERIOR SOBER HOUSE
Entity type:Organization
Organization Name:SUPERIOR SOBER HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:REDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:CHW,CPRC
Authorized Official - Phone:248-563-9988
Mailing Address - Street 1:PO BOX 822
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0822
Mailing Address - Country:US
Mailing Address - Phone:248-536-9988
Mailing Address - Fax:
Practice Address - Street 1:620 S LAKE ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5150
Practice Address - Country:US
Practice Address - Phone:248-563-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPERIOR SOBER HOUSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty