Healthcare Provider Details

I. General information

NPI: 1760969935
Provider Name (Legal Business Name): TAYLOR C'MON SHACKELFORD EP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 GRASSLAND PKWY
ALPHARETTA GA
30004
US

IV. Provider business mailing address

1755 GRASSLAND PKWY
ALPHARETTA GA
30004-8600
US

V. Phone/Fax

Practice location:
  • Phone: 678-580-1404
  • Fax:
Mailing address:
  • Phone: 678-580-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: