Provider Demographics
NPI:1851516744
Name:SCOOTER MALL
Entity Type:Organization
Organization Name:SCOOTER MALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:SCIVALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-489-4503
Mailing Address - Street 1:2316 MEMORIAL PKWY NW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35810-4506
Mailing Address - Country:US
Mailing Address - Phone:256-489-4503
Mailing Address - Fax:256-489-4506
Practice Address - Street 1:2316 MEMORIAL PKWY NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-4506
Practice Address - Country:US
Practice Address - Phone:256-489-4503
Practice Address - Fax:256-489-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL090187332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies