Healthcare Provider Details

I. General information

NPI: 1023653714
Provider Name (Legal Business Name): AUNDRAY TERALL SHACKELFORD PROSTHETICSPECIALIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2019
Last Update Date: 11/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 RANKIN BLVD EXT
TUPELO MS
38801-4611
US

IV. Provider business mailing address

204 CITY POINT RD
TUPELO MS
38801-8637
US

V. Phone/Fax

Practice location:
  • Phone: 662-260-1239
  • Fax:
Mailing address:
  • Phone: 662-260-1239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: