MEDICARE: SHELLMIRE UNLIMITED, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	2376	OR

General Provider Information

NPI Number	:	1659793107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHELLMIRE UNLIMITED, P.C.

Provider Business Mailing Address
First Line	:	4134 N VANCOUVER AVENUE, SUITE 102
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217
Country	:	US
Telephone Number	:	503-331-2548
Fax Number	:	503-331-2549

Provider Business Practice Location Address
First Line	:	4134 N VANCOUVER AVENUE, SUITE 102
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217
Country	:	US
Telephone Number	:	503-331-2548
Fax Number	:	503-331-2549

Authorized Official
Title or Position	:	CEO
Name	:	RAY SHELLMIRE
Credential	:	MSW, LCSW
Telephone Number	:	503-803-2309

Provider Enumeration Date	:	01/16/2014
Last Update Date	:	01/16/2014

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