1487760112 NPI number — SPECIALIZED MOBILITY, LLC

Table of content: (NPI 1487760112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487760112 NPI number — SPECIALIZED MOBILITY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED MOBILITY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487760112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLENTINE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29002-0545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-749-3613
Provider Business Mailing Address Fax Number:
803-749-0263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2361 DUTCH FORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPIN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29036-8569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-749-3613
Provider Business Practice Location Address Fax Number:
803-749-0263
Provider Enumeration Date:
08/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
O'CONNOR
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
PHILLIP
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-749-3613

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DME981 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".