Provider Demographics
NPI:1164485249
Name:SCANLON, BRUCE GLEN (ATC/R)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:GLEN
Last Name:SCANLON
Suffix:
Gender:M
Credentials:ATC/R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-3317
Mailing Address - Country:US
Mailing Address - Phone:503-565-4357
Mailing Address - Fax:
Practice Address - Street 1:615 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3317
Practice Address - Country:US
Practice Address - Phone:503-565-4357
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-1155252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer