Healthcare Provider Details

I. General information

NPI: 1568532620
Provider Name (Legal Business Name): SHAKER CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 E BROAD ST
COLUMBUS OH
43205-1156
US

IV. Provider business mailing address

6100 TOWER CIR STE 1000
FRANKLIN TN
37067-1509
US

V. Phone/Fax

Practice location:
  • Phone: 614-928-9400
  • Fax: 614-928-9401
Mailing address:
  • Phone: 615-861-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0519
License Number StateOH

VIII. Authorized Official

Name: MR. CHRISTOPHER L HOWARD
Title or Position: VP & SECRETARY
Credential:
Phone: 615-861-6000