Provider Demographics
NPI:1346684289
Name:POWER CHAIRS AND SCOOTER STORE MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:POWER CHAIRS AND SCOOTER STORE MEDICAL SUPPLY LLC
Other - Org Name:FOREST LAKE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-982-0002
Mailing Address - Street 1:540 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-1659
Mailing Address - Country:US
Mailing Address - Phone:320-629-1149
Mailing Address - Fax:320-629-1287
Practice Address - Street 1:540 MAIN ST S
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:320-629-1149
Practice Address - Fax:320-629-1287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1447560057Medicaid
MN1346684289Medicaid