Healthcare Provider Details

I. General information

NPI: 1619304060
Provider Name (Legal Business Name): MR. SCOTT GORDON ROSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 FOREST HOLLOW WAY
SAINT JOHNS FL
32259-2949
US

IV. Provider business mailing address

2121 FOREST HOLLOW WAY
SAINT JOHNS FL
32259-2949
US

V. Phone/Fax

Practice location:
  • Phone: 904-342-6844
  • Fax:
Mailing address:
  • Phone: 904-342-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberCRC-057575
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: