1477808673 NPI number — LUKE ANTHONY SCOTT DPT

Table of content: LUKE ANTHONY SCOTT DPT (NPI 1477808673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477808673 NPI number — LUKE ANTHONY SCOTT DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
LUKE
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477808673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24630 WASHINGTON AVE
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-6131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-9353
Provider Business Mailing Address Fax Number:
951-973-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
521 E ELDER ST
Provider Second Line Business Practice Location Address:
STE. 106
Provider Business Practice Location Address City Name:
FALLBROOK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92028-3081
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-723-8337
Provider Business Practice Location Address Fax Number:
760-723-5476
Provider Enumeration Date:
07/13/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT 39184 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0PT391840 . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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