1578586434 NPI number — SCOOTER STORE - SHREVEPORT LLC

Table of content: (NPI 1578586434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578586434 NPI number — SCOOTER STORE - SHREVEPORT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOOTER STORE - SHREVEPORT 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:
6
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:
1578586434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 310709
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78131-0709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9644 SAINT VINCENT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71106-7127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-865-1564
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CONE
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL COUNSEL & SECRETARY
Authorized Official Telephone Number:
830-627-4433

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 157486502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 149016716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157486501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157486504 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 157486503 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1120006 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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