Provider Demographics
NPI:1447560057
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
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-982-0002
Mailing Address - Street 1:255 HIGHWAY 97
Mailing Address - Street 2:7B
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2697
Mailing Address - Country:US
Mailing Address - Phone:651-982-0002
Mailing Address - Fax:651-982-0030
Practice Address - Street 1:255 HIGHWAY 97
Practice Address - Street 2:7B
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2697
Practice Address - Country:US
Practice Address - Phone:651-982-0002
Practice Address - Fax:651-982-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2018-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1447560057Medicaid