Provider Demographics
NPI:1487760112
Name:SPECIALIZED MOBILITY, LLC
Entity type:Organization
Organization Name:SPECIALIZED MOBILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-749-3613
Mailing Address - Street 1:PO BOX 545
Mailing Address - Street 2:
Mailing Address - City:BALLENTINE
Mailing Address - State:SC
Mailing Address - Zip Code:29002-0545
Mailing Address - Country:US
Mailing Address - Phone:803-749-3613
Mailing Address - Fax:803-749-0263
Practice Address - Street 1:2361 DUTCH FORK RD
Practice Address - Street 2:
Practice Address - City:CHAPIN
Practice Address - State:SC
Practice Address - Zip Code:29036-8569
Practice Address - Country:US
Practice Address - Phone:803-749-3613
Practice Address - Fax:803-749-0263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDME981Medicaid
SC4469080001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #