MEDICARE: SUPERIOR VAN & MOBILITY

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	171WV0202X	Vehicle Modifications Contractor	205552	IN

General Provider Information

NPI Number	:	1720166853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPERIOR VAN & MOBILITY

Provider Business Mailing Address
First Line	:	1506 LAKE SHORE CT
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3803
Country	:	US
Telephone Number	:	800-458-8267
Fax Number	:	502-447-5768

Provider Business Practice Location Address
First Line	:	2218 CONTRACTORS WAY
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1721
Country	:	US
Telephone Number	:	260-497-8267
Fax Number	:	260-490-4484

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SAM COOK
Credential	:
Telephone Number	:	800-458-8267

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	02/03/2026

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