=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790989754
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOS BUISNESS TRUST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 STONECREST PKWY SUITE 210
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37167-6826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-459-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3918 DICKERSON PIKE SUITE 114
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37207-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TRUSTEE PRACTITIONER
-----------------------------------------------------
Name | BJ STAGNER JR.
-----------------------------------------------------
Credential | C.P.O.
-----------------------------------------------------
Telephone | 615-868-7626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 4
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 3
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------