Healthcare Provider Details

I. General information

NPI: 1194488007
Provider Name (Legal Business Name): SOS TRANSITIONAL LIVING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 BROADWAY DR
HATTIESBURG MS
39401-5084
US

IV. Provider business mailing address

2008 S 28TH AVENUE EXT
HATTIESBURG MS
39402-3450
US

V. Phone/Fax

Practice location:
  • Phone: 601-441-2220
  • Fax: 601-602-1059
Mailing address:
  • Phone: 601-441-2220
  • Fax: 601-602-1059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: RICKETIA ESTELLA MCKENZIE
Title or Position: MANAGER, CEO
Credential:
Phone: 601-441-2220