Provider Demographics
NPI:1689739120
Name:SCATTER CREEK PROSTHETICS INC.
Entity Type:Organization
Organization Name:SCATTER CREEK PROSTHETICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:360-264-6553
Mailing Address - Street 1:225 143RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9604
Mailing Address - Country:US
Mailing Address - Phone:360-264-6553
Mailing Address - Fax:
Practice Address - Street 1:548 SUSSEX AVE W
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9341
Practice Address - Country:US
Practice Address - Phone:360-264-6553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1234640001Medicare NSC