1255766572 NPI number — SHENELLE LLC

Table of content: PEDRO ANTONIO PEREZ CARABALLO MA, MS (NPI 1871267880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255766572 NPI number — SHENELLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHENELLE 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:
1255766572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 44445
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30336-1445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-373-9600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3670 MCCLURE BRIDGE RD
Provider Second Line Business Practice Location Address:
STE 4141
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-556-8670
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
BERNARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
877-373-9600

Provider Taxonomy Codes

  • Taxonomy code: 311Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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