Healthcare Provider Details

I. General information

NPI: 1902252679
Provider Name (Legal Business Name): SHAUNA NOELCKE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 SYCAMORE AVE APT 1112
CHARLESTON SC
29407-6732
US

IV. Provider business mailing address

45 SYCAMORE AVE APT 1112
CHARLESTON SC
29407-6732
US

V. Phone/Fax

Practice location:
  • Phone: 937-430-2436
  • Fax:
Mailing address:
  • Phone: 937-430-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number7144
License Number StateSC

VIII. Authorized Official

Name: SHAUNA NOELCKE
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 937-430-2436