Healthcare Provider Details

I. General information

NPI: 1891937306
Provider Name (Legal Business Name): SHANNON DENISE REILLY CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5494 PONY EXPRESS TRAIL
POLLOCK PINES CA
95726
US

IV. Provider business mailing address

PO BOX 586
CAMINO CA
95709-0586
US

V. Phone/Fax

Practice location:
  • Phone: 530-644-3758
  • Fax: 530-644-3782
Mailing address:
  • Phone: 530-644-3758
  • Fax: 530-644-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number324500000X
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: