Healthcare Provider Details

I. General information

NPI: 1427003201
Provider Name (Legal Business Name): SPECIALIZED OXYGEN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 EXECUTIVE DR SUITE 102
HIXSON TN
37343-3991
US

IV. Provider business mailing address

PO BOX 965
HIXSON TN
37343-0965
US

V. Phone/Fax

Practice location:
  • Phone: 423-847-0031
  • Fax: 423-847-0525
Mailing address:
  • Phone: 423-847-0031
  • Fax: 423-847-0525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number0000000727
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000974366A
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerDME PROVIDER # GAMCAID
# 2
Identifier1454230
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 3
Identifier4049414
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerDME PROVIDER # BC/BS

VIII. Authorized Official

Name: KIMBERLY DENEISE STANDEFER
Title or Position: PRESIDENT (CO-OWNER)
Credential: RN, BS
Phone: 423-847-0031