Provider Demographics
NPI:1033536255
Name:SORC, LLC
Entity Type:Organization
Organization Name:SORC, LLC
Other - Org Name:SORC REGROWTH
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOOT
Authorized Official - Suffix:
Authorized Official - Credentials:CDCA
Authorized Official - Phone:419-378-9212
Mailing Address - Street 1:723 PHILLIPS AVE BLDG E
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-1351
Mailing Address - Country:US
Mailing Address - Phone:419-407-5981
Mailing Address - Fax:
Practice Address - Street 1:11811 NORTH FWY STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-3244
Practice Address - Country:US
Practice Address - Phone:419-378-9212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 207Q00000X, 251B00000X, 251S00000X
OH13527251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1134667538Medicaid
MI1134667538Medicaid
TX1396076543Medicaid
TX4226219Medicaid
TX4234783Medicaid
TX1134667538Medicaid
TX1033536255Medicaid
OH1063629608Medicaid
MI1063629608Medicaid