MEDICARE: SOUTHERN RIDE MOBILITY 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1902587595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN RIDE MOBILITY LLC

Provider Business Mailing Address
First Line	:	287 DOOLEY RD STE A
Second Line	:	287 DOOLEY RD STE A
City	:	LEXINGTON
State	:	SC
Zip	:	29073-7614
Country	:	US
Telephone Number	:	803-661-3331
Fax Number	:

Provider Business Practice Location Address
First Line	:	287 DOOLEY RD STE A287
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-7614
Country	:	US
Telephone Number	:	803-661-3331
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARC H SUDDARTH
Credential	:
Telephone Number	:	803-661-3331

Provider Enumeration Date	:	07/27/2023
Last Update Date	:	07/27/2023

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