Provider Demographics
NPI:1750788642
Name:THORNTON, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:THORNTON
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 1:118 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:RI
Mailing Address - Zip Code:02816-7354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:RI
Practice Address - Zip Code:02816-7354
Practice Address - Country:US
Practice Address - Phone:401-644-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT02066225700000X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist