Provider Demographics
NPI:1154379980
Name:SCOOTER MART
Entity type:Organization
Organization Name:SCOOTER MART
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:SONGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-855-1212
Mailing Address - Street 1:5142 RICHTER ST
Mailing Address - Street 2:BLDG A
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78415-2035
Mailing Address - Country:US
Mailing Address - Phone:361-855-1212
Mailing Address - Fax:361-855-1212
Practice Address - Street 1:5142 RICHTER ST
Practice Address - Street 2:BLDG A
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-2035
Practice Address - Country:US
Practice Address - Phone:361-855-1212
Practice Address - Fax:361-855-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0044164332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010956302Medicaid
TX140663901Medicaid
TX531206OtherD.M.E.
TX140663901Medicaid