1629094016 NPI number — SCOOTER STORE DETROIT LLC

Table of content: (NPI 1629094016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629094016 NPI number — SCOOTER STORE DETROIT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOOTER STORE DETROIT 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:
1629094016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2013
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:
22640 15 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLINTON TOWNSHIP
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48035-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-746-1032
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/15/2006

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:
830-267-4433

Provider Taxonomy Codes

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

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

  • Identifier: 2555257 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4582100 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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