Healthcare Provider Details

I. General information

NPI: 1346439049
Provider Name (Legal Business Name): GARY SHELTON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 E SHERIDAN RD
MELBOURNE FL
32901-3227
US

IV. Provider business mailing address

436 FRANKLIN ST
PADUCAH KY
42003-0435
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-0984
  • Fax:
Mailing address:
  • Phone: 270-556-3842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number13961
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: