1306990601 NPI number — SHAMROCK SERVICES, LLC

Table of content: (NPI 1306990601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306990601 NPI number — SHAMROCK SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHAMROCK SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306990601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62864-0046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-244-7701
Provider Business Mailing Address Fax Number:
618-244-7704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4219 LINCOLNSHIRE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62864-2157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-242-2169
Provider Business Practice Location Address Fax Number:
618-242-9770
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCDONAGH
Authorized Official First Name:
BRIDGET
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
618-244-7701

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  94S227 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 94S227 . This is a "CILA LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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