Basic Information
Provider Information | |||||||||
NPI: | 1003860941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOTTO INTERNATIONAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SERENITY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5314 SOUTH YALE AVE | ||||||||
Address2: | SUITE 420 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741356271 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187704441 | ||||||||
FaxNumber: | 9187129880 | ||||||||
Practice Location | |||||||||
Address1: | 1316 E. MAIN STREET | ||||||||
Address2: |   | ||||||||
City: | MAGNOLIA | ||||||||
State: | AR | ||||||||
PostalCode: | 717533826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8663679445 | ||||||||
FaxNumber: | 9187129880 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2006 | ||||||||
LastUpdateDate: | 06/02/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUHN | ||||||||
AuthorizedOfficialFirstName: | ROGER | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
AuthorizedOfficialTelephone: | 9188943487 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | AR4247 | AR | Y |   | Agencies | Hospice Care, Community Based |   |
ID Information
ID | Type | State | Issuer | Description | 158725747 | 05 | AR |   | MEDICAID |