1174097000 NPI number — SHELBIE C CALK GREENVILLE MS, RDN, LD

Table of content: SHELBIE C CALK GREENVILLE MS, RDN, LD (NPI 1174097000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174097000 NPI number — SHELBIE C CALK GREENVILLE MS, RDN, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CALK GREENVILLE
Provider First Name:
SHELBIE
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RDN, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALK
Provider Other First Name:
SHELBIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174097000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 EDGEWOOD CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-7518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-465-6997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 N STALLINGS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NACOGDOCHES
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75964-1222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-205-1721
Provider Business Practice Location Address Fax Number:
866-259-8676
Provider Enumeration Date:
01/14/2019

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: 133V00000X , with the licence number:  DT85139 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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