Healthcare Provider Details

I. General information

NPI: 1669839742
Provider Name (Legal Business Name): TARA SHELLEY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 ASHLAND AVE
CLINTON SC
29325-2960
US

IV. Provider business mailing address

973 OLD MILTON RD
CLINTON SC
29325-6154
US

V. Phone/Fax

Practice location:
  • Phone: 864-200-0636
  • Fax:
Mailing address:
  • Phone: 904-392-9518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1692
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: