Provider Demographics
NPI:1235553041
Name:SCOTT, ROD (ATC, CES, PES)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:ATC, CES, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EVERBANK FIELD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-1928
Mailing Address - Country:US
Mailing Address - Phone:904-633-6561
Mailing Address - Fax:904-633-6070
Practice Address - Street 1:1 EVERBANK FIELD DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-1928
Practice Address - Country:US
Practice Address - Phone:904-633-6561
Practice Address - Fax:904-633-6070
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL49677212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLTAXONOMY CODE 2255A2OtherPROVIDER TYPE 22