Healthcare Provider Details

I. General information

NPI: 1083314488
Provider Name (Legal Business Name): SHIVANI SHAH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 LAKE JOY RD STE D
HOUSTON GA
31947
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 478-313-5385
  • Fax: 478-313-5429
Mailing address:
  • Phone: 866-518-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016473
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: