Provider Demographics
NPI:1114395266
Name:WAMBOLD, SCOTT (LMT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:WAMBOLD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 LECKLER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-9264
Mailing Address - Country:US
Mailing Address - Phone:503-781-4606
Mailing Address - Fax:
Practice Address - Street 1:450 LECKLER CREEK RD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-9264
Practice Address - Country:US
Practice Address - Phone:503-781-4606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-07
Last Update Date:2015-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60547514172M00000X
OR21344172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist