Provider Demographics
NPI:1104848100
Name:SCOOTER STORE - SALT LAKE CITY LLC
Entity Type:Organization
Organization Name:SCOOTER STORE - SALT LAKE CITY LLC
Other - Org Name:THE SCOOTER STORE/ALLIANCE SEATING & MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL COUNSEL & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:CONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-627-4433
Mailing Address - Street 1:PO BOX 310709
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78131-0709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4894 COMMERCE DR STE D
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4787
Practice Address - Country:US
Practice Address - Phone:801-281-0553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SCOOTER STORE - USA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118422900Medicaid
ID1104848100Medicaid
NV1104848100Medicaid
NV1104848100Medicaid
UT=========001Medicaid