1346935020 NPI number — SHINE HEALTHCARE GROUP

Table of content: (NPI 1346935020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346935020 NPI number — SHINE HEALTHCARE GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHINE HEALTHCARE GROUP
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:
1346935020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3631 CHAMBLEE TUCKER RD STE A288
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:
30341-4415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 CHURCH ST STE 2000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37219-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-870-2402
Provider Business Practice Location Address Fax Number:
404-393-3441
Provider Enumeration Date:
04/07/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOOKER
Authorized Official First Name:
JASMIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
404-491-7716

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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