MEDICARE: SCOOTER STORE - SHREVEPORT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)		TX
2	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578586434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOOTER STORE - SHREVEPORT LLC

Provider Business Mailing Address
First Line	:	PO BOX 310709
Second Line	:
City	:	NEW BRAUNFELS
State	:	TX
Zip	:	78131-0709
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9644 SAINT VINCENT AVE
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71106-7127
Country	:	US
Telephone Number	:	318-865-1564
Fax Number	:

Authorized Official
Title or Position	:	GENERAL COUNSEL & SECRETARY
Name	:	JASON CONE
Credential	:
Telephone Number	:	830-627-4433

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	08/09/2013

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Directions to “SCOOTER STORE - SHREVEPORT LLC ” Practice Location

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