Healthcare Provider Details

I. General information

NPI: 1275829079
Provider Name (Legal Business Name): SHELL'S SHUTTLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 CHARLOTTE CT #8
ANTIGO WI
54409-2970
US

IV. Provider business mailing address

2429 CHARLOTTE CT #8
ANTIGO WI
54409-2970
US

V. Phone/Fax

Practice location:
  • Phone: 715-846-5989
  • Fax:
Mailing address:
  • Phone: 715-846-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number273JTT
License Number StateWI

VIII. Authorized Official

Name: MR. WILLIAM F MOFFAT III
Title or Position: VICE-PRESIDENT
Credential:
Phone: 715-846-5989