=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558642074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOS INFUSION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2011
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1514 PECAN TRACE CT
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-6224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 123-456-7890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 PECAN TRACE CT
-----------------------------------------------------
City | SUGAR LAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77479-6224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MARK ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 123-456-7890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------