Provider Demographics
NPI:1164561775
Name:SCAMMON CREEK PHYSICAL THERAPY
Entity Type:Organization
Organization Name:SCAMMON CREEK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRANDI
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:360-330-9346
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:LITTLEROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98556-0383
Mailing Address - Country:US
Mailing Address - Phone:360-330-9346
Mailing Address - Fax:360-330-9347
Practice Address - Street 1:2700 COLONIAL DR
Practice Address - Street 2:#305
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-8869
Practice Address - Country:US
Practice Address - Phone:360-330-9346
Practice Address - Fax:360-330-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602410734261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8806943Medicare ID - Type Unspecified