Healthcare Provider Details

I. General information

NPI: 1114400553
Provider Name (Legal Business Name): DENISE Q SHEPARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1895 BATTLEFIELD PKWY
FORT OGLETHORPE GA
30742-4021
US

IV. Provider business mailing address

1895 BATTLEFIELD PKWY
FORT OGLETHORPE GA
30742-4021
US

V. Phone/Fax

Practice location:
  • Phone: 706-861-7166
  • Fax: 706-861-1799
Mailing address:
  • Phone: 706-861-7166
  • Fax: 706-861-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: CANDY K HOUSLEY
Title or Position: OFFICE
Credential:
Phone: 706-861-7166