Healthcare Provider Details

I. General information

NPI: 1104848100
Provider Name (Legal Business Name): SCOOTER STORE - SALT LAKE CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4894 COMMERCE DR STE D
MURRAY UT
84107-4787
US

IV. Provider business mailing address

PO BOX 310709
NEW BRAUNFELS TX
78131-0709
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-0553
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JASON CONE
Title or Position: GENERAL COUNSEL & SECRETARY
Credential:
Phone: 830-627-4433