Healthcare Provider Details

I. General information

NPI: 1174793533
Provider Name (Legal Business Name): SHAFFER RAINEY DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2008
Last Update Date: 07/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BUSINESS PARK DR STE C
BRANSON MO
65616-7426
US

IV. Provider business mailing address

110 BUSINESS PARK DRIVE SUITE C
BRANSON MO
65616-8156
US

V. Phone/Fax

Practice location:
  • Phone: 417-239-0125
  • Fax:
Mailing address:
  • Phone: 417-239-0125
  • Fax: 417-239-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2007035572
License Number StateMO

VIII. Authorized Official

Name: DR. CHRISTY SHAFFER RAINEY
Title or Position: OWNER
Credential: M.D.
Phone: 417-239-0125