Provider Demographics
NPI:1710079983
Name:GREAT AMERICAN SCOOTER COMPANY GOLDEN TRIANGLE LLC
Entity Type:Organization
Organization Name:GREAT AMERICAN SCOOTER COMPANY GOLDEN TRIANGLE LLC
Other - Org Name:GREAT AMERICAN MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-833-8300
Mailing Address - Street 1:65 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-2224
Mailing Address - Country:US
Mailing Address - Phone:409-833-8300
Mailing Address - Fax:409-833-8301
Practice Address - Street 1:65 N 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-2224
Practice Address - Country:US
Practice Address - Phone:409-833-8300
Practice Address - Fax:409-833-8301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX332BD1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159927601Medicaid
TX159927602Medicaid
TX531789OtherBLUE CROSS BLUE SHIELD
TX4797560001Medicare NSC