Provider Demographics
NPI:1053648923
Name:KING, SCOTT GLEN (MPT)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:GLEN
Last Name:KING
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-1056
Mailing Address - Country:US
Mailing Address - Phone:208-477-8028
Mailing Address - Fax:
Practice Address - Street 1:103 S COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2921
Practice Address - Country:US
Practice Address - Phone:208-477-8028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist