Provider Demographics
NPI:1366764045
Name:CLEAN ADVENTURES OF SOBER LIVING, LLC
Entity type:Organization
Organization Name:CLEAN ADVENTURES OF SOBER LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CARSON
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-443-8767
Mailing Address - Street 1:534 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2433
Mailing Address - Country:US
Mailing Address - Phone:928-443-8767
Mailing Address - Fax:928-776-4781
Practice Address - Street 1:534 MADISON AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2433
Practice Address - Country:US
Practice Address - Phone:928-443-8767
Practice Address - Fax:928-776-4781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3525251S00000X
AZOTC6727251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health