1558401828 NPI number — MR. AARON DAVID SHAMBLIN OTR L

Table of content: MR. AARON DAVID SHAMBLIN OTR L (NPI 1558401828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558401828 NPI number — MR. AARON DAVID SHAMBLIN OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAMBLIN
Provider First Name:
AARON
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR L
Provider Gender Code:
M

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:
1558401828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15055 W CHARTER OAK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85379-5921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-826-8908
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15802 NORTH PARKVIEW PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SURPRISE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-876-7022
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

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: 225X00000X , with the licence number:  3129 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 818544 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com