=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336389352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL SHORUNKE LVN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2009
-----------------------------------------------------
Last Update Date | 03/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2306 MONTEGO DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76002-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-323-9981
-----------------------------------------------------
Fax | 817-470-4162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2306 MONTEGO DR
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76002-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-323-9981
-----------------------------------------------------
Fax | 817-470-4162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------