Provider Demographics
NPI:1689187445
Name:SCANLIN, MATTHEW JOHN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:SCANLIN
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 1:5485 55TH ST APT 7C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1260
Mailing Address - Country:US
Mailing Address - Phone:209-770-3440
Mailing Address - Fax:
Practice Address - Street 1:5555 DEL MAR HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-1368
Practice Address - Country:US
Practice Address - Phone:209-770-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer