Healthcare Provider Details

I. General information

NPI: 1689739120
Provider Name (Legal Business Name): SCATTER CREEK PROSTHETICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 SUSSEX AVE W
TENINO WA
98589-9341
US

IV. Provider business mailing address

225 143RD AVE SE
TENINO WA
98589-9604
US

V. Phone/Fax

Practice location:
  • Phone: 360-264-6553
  • Fax:
Mailing address:
  • Phone: 360-264-6553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GENE RUCKER
Title or Position: PRESIDENT
Credential: LPO
Phone: 360-264-6553