Provider Demographics
NPI:1932283439
Name:SCOTT, DOMINIQUE MATTHEW
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:MATTHEW
Last Name:SCOTT
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 1:510 N PROSPECT AVE
Mailing Address - Street 2:STE.207
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3028
Mailing Address - Country:US
Mailing Address - Phone:310-376-5433
Mailing Address - Fax:
Practice Address - Street 1:510 N PROSPECT AVE
Practice Address - Street 2:STE.207
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3028
Practice Address - Country:US
Practice Address - Phone:310-376-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25377111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0253770OtherBLUE SHIELD PROVIDER #
CAP00136906OtherPALMETTO GBA RAIL ROAD
CAWDC25377AMedicare ID - Type UnspecifiedMEMBER ID
CAP00136906OtherPALMETTO GBA RAIL ROAD