1679557003 NPI number — KENNETH SCOTT CALL PT

Table of content: KENNETH SCOTT CALL PT (NPI 1679557003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679557003 NPI number — KENNETH SCOTT CALL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALL
Provider First Name:
KENNETH
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1679557003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 N LOUISIANA ST
Provider Second Line Business Practice Location Address:
STE 104 A
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-7167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-783-1962
Provider Business Practice Location Address Fax Number:
509-783-1706
Provider Enumeration Date:
11/30/2005

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:  3221 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00006307 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G8966495 . This is a "MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1679557003 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8336646 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 650013327 . This is a "RR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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