Provider Demographics
NPI:1407521933
Name:SOSAB
Entity type:Organization
Organization Name:SOSAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHENITA-ANN
Authorized Official - Middle Name:PATRECE
Authorized Official - Last Name:GRYMES
Authorized Official - Suffix:
Authorized Official - Credentials:CHC
Authorized Official - Phone:800-681-4180
Mailing Address - Street 1:700 PENNSYLVANIA AVE SE FL 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2493
Mailing Address - Country:US
Mailing Address - Phone:800-681-4180
Mailing Address - Fax:800-681-4180
Practice Address - Street 1:700 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2493
Practice Address - Country:US
Practice Address - Phone:800-681-4180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty