Healthcare Provider Details

I. General information

NPI: 1770661803
Provider Name (Legal Business Name): SUPERIOR VAN & MOBILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3725 CLEVELAND ROAD EXT SUITE 400
SOUTH BEND IN
46628-9779
US

IV. Provider business mailing address

4734 ROCKFORD PLZ
LOUISVILLE KY
40216-2631
US

V. Phone/Fax

Practice location:
  • Phone: 574-271-1175
  • Fax: 574-271-1546
Mailing address:
  • Phone: 800-458-8267
  • Fax: 502-447-5768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License Number127842
License Number StateIN

VIII. Authorized Official

Name: MR. SAM COOK
Title or Position: OWNER
Credential:
Phone: 800-458-8267