Provider Demographics
NPI:1235728668
Name:SECONDO, SCOTT R
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:SECONDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2996 RUMSEY ST
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-5264
Mailing Address - Country:US
Mailing Address - Phone:916-295-2549
Mailing Address - Fax:
Practice Address - Street 1:1166 BROADWAY STE T
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5745
Practice Address - Country:US
Practice Address - Phone:530-621-2273
Practice Address - Fax:916-436-4770
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA094700015374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide