Healthcare Provider Details

I. General information

NPI: 1104082684
Provider Name (Legal Business Name): SCOTT RAMON LUALLEN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 AIRPORT DR. BUILDING C SUITE 160
COLUMBUS OH
43219
US

IV. Provider business mailing address

194 STONEMAST LOOP
PATASKALA OH
43062-7325
US

V. Phone/Fax

Practice location:
  • Phone: 614-866-8158
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3134
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: