Provider Demographics
NPI:1417940891
Name:SCOTT, THEODORE JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:JOHN
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 E 450 N
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-1682
Mailing Address - Country:US
Mailing Address - Phone:801-589-7755
Mailing Address - Fax:
Practice Address - Street 1:180 W GORDON AVE 1000 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2340
Practice Address - Country:US
Practice Address - Phone:801-544-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162508-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000005654Medicare UPIN