Provider Demographics
NPI:1992846406
Name:FREEDOM CARS MOBILITY STORE
Entity Type:Organization
Organization Name:FREEDOM CARS MOBILITY STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCKINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-429-6323
Mailing Address - Street 1:4711 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3268
Mailing Address - Country:US
Mailing Address - Phone:651-429-6323
Mailing Address - Fax:651-429-0308
Practice Address - Street 1:4711 CLARK AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3268
Practice Address - Country:US
Practice Address - Phone:651-429-6323
Practice Address - Fax:651-429-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8139026332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN303L9MCOtherBLUE CROSS CLUE SHIELD
MN5988580001Medicare NSC