Healthcare Provider Details

I. General information

NPI: 1669964888
Provider Name (Legal Business Name): SHANNON CEARA SHOOP PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHANNON CEARA PALACIOS PTA

II. Dates (important events)

Enumeration Date: 06/04/2018
Last Update Date: 06/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E TINKHAM AVE
LUDINGTON MI
49431-1536
US

IV. Provider business mailing address

901 E TINKHAM AVE
LUDINGTON MI
49431-1536
US

V. Phone/Fax

Practice location:
  • Phone: 231-843-2676
  • Fax: 231-843-2209
Mailing address:
  • Phone: 231-843-2676
  • Fax: 231-843-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5502004116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: