=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366483810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOOTER MART INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 S LAMAR
-----------------------------------------------------
City | EASTLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-629-2416
-----------------------------------------------------
Fax | 254-629-0998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 S LAMAR
-----------------------------------------------------
City | EASTLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 254-629-2416
-----------------------------------------------------
Fax | 254-629-0998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KEN WAYNE SONGER
-----------------------------------------------------
Credential | LUTCF
-----------------------------------------------------
Telephone | 254-629-2416
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------