1437609773 NPI number — WESTSIDE SOBER LIVING CENTERS, INC

Table of content: (NPI 1437609773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437609773 NPI number — WESTSIDE SOBER LIVING CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE SOBER LIVING CENTERS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROMISES PTP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437609773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 670549
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75267-0549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-567-7282
Provider Business Mailing Address Fax Number:
615-261-8912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2515 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403-4615
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-595-3105
Provider Business Practice Location Address Fax Number:
424-272-9303
Provider Enumeration Date:
10/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MAPLESDEN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
SR DIRECTOR RCM
Authorized Official Telephone Number:
615-510-3708

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  190625GP , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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