Provider Demographics
NPI:1164508776
Name:STEVE'S VANS & ACCESSORIES UNLIMITED LLC
Entity Type:Organization
Organization Name:STEVE'S VANS & ACCESSORIES UNLIMITED LLC
Other - Org Name:MARIETTA MOBILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HESSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-374-3154
Mailing Address - Street 1:211 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-3349
Mailing Address - Country:US
Mailing Address - Phone:740-374-3154
Mailing Address - Fax:740-374-9713
Practice Address - Street 1:211 S 8TH ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3349
Practice Address - Country:US
Practice Address - Phone:740-374-3154
Practice Address - Fax:740-374-9713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH84018902332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311099975002OtherMEDICAL MUTUAL OF OHIO
OH000000242032OtherANTHEM BLUE CROSS BLUE SH
OH2015250OtherMEDICAL CASE MANAGEMENT
WV6204048000Medicaid
OH2015250Medicaid
OH31109997500OtherBWC
OH8400493OtherMRDD
OH2015250OtherMEDICAL CASE MANAGEMENT