=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609004381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOS HEALTHCARE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2009
-----------------------------------------------------
Last Update Date | 07/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 980 N WALNUT CREEK DR SUITE 100
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-8019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-477-5700
-----------------------------------------------------
Fax | 817-477-9122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 E BROAD ST
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-1706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. CHARLES C STIDHAM JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-477-9494
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------