Healthcare Provider Details

I. General information

NPI: 1538884697
Provider Name (Legal Business Name): SHOAL CREEK FOOT AND ANKLE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2022
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4136 S MCCANN CT
SPRINGFIELD MO
65804-7253
US

IV. Provider business mailing address

1801 W 32ND ST STE 102
JOPLIN MO
64804-1528
US

V. Phone/Fax

Practice location:
  • Phone: 417-755-7612
  • Fax:
Mailing address:
  • Phone: 417-622-0648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: SHELLY DIANE SEDBERRY
Title or Position: PHYSICIAN/OWNER
Credential: DPM
Phone: 417-622-0648