Provider Demographics
NPI:1700818192
Name:AGBINCOLA, SCOTT (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:AGBINCOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7730 PASEO DEL REY APT 1
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8345
Mailing Address - Country:US
Mailing Address - Phone:310-643-9016
Mailing Address - Fax:310-536-0177
Practice Address - Street 1:2250 PARK PL
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4908
Practice Address - Country:US
Practice Address - Phone:310-643-9016
Practice Address - Fax:310-536-0177
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT28894Medicare ID - Type UnspecifiedPT