=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134016553
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVVY SHAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2025
-----------------------------------------------------
Last Update Date | 07/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1296 E GIBSON RD STE A259
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95776-6378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-836-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1296 E GIBSON RD STE A259
-----------------------------------------------------
City | WOODLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95776-6378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-836-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EBONY THOMAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-460-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------