Healthcare Provider Details

I. General information

NPI: 1215995832
Provider Name (Legal Business Name): SHAWN TAYLOR GALBRAITH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LRMC CMR 402 BOX 1778
APO AE
09180
DE

IV. Provider business mailing address

11 WINZENWEG
KOLLWEILER GERMANY
66879
DE

V. Phone/Fax

Practice location:
  • Phone: 06371866504
  • Fax:
Mailing address:
  • Phone: 208-356-3926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100035
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: