Healthcare Provider Details

I. General information

NPI: 1194435149
Provider Name (Legal Business Name): SOS PHOENIX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 S LONGMORE STE 2
MESA AZ
85202-9607
US

IV. Provider business mailing address

5018 E HANNIBAL ST
MESA AZ
85205-6879
US

V. Phone/Fax

Practice location:
  • Phone: 801-635-6208
  • Fax:
Mailing address:
  • Phone: 801-635-6208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TED HOLMGREN
Title or Position: OWNER, GENERAL MANAGER
Credential:
Phone: 801-635-6208