1679604599 NPI number — TERRE STRUBE SHANKLE CNM

Table of content: TERRE STRUBE SHANKLE CNM (NPI 1679604599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679604599 NPI number — TERRE STRUBE SHANKLE CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANKLE
Provider First Name:
TERRE
Provider Middle Name:
STRUBE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

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:
1679604599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2720 SUNSET BLVD
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
WEST COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29169-4810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-936-7679
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2728 SUNSET BLVD
Provider Second Line Business Practice Location Address:
STE 201
Provider Business Practice Location Address City Name:
WEST COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29169-4840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-936-8100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  APRN 264 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MW0091 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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