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General NPI Number Information
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NPI Number | 1477810745
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Entity Type | Individual
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Provider Name | RONALD P. SHELTON A.T.,C./L
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Gender | Male
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Dates
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Enumeration Date | 04/11/2012
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Last Update Date | 04/11/2012
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Provider Practice Location Address
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Address Line | 4675 BLUESTEM RD # 1
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City | ROSCOE
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State | IL
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Zip | 61073-7788
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Country | US
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Telephone | 815-623-9930
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Fax |
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Provider Business Mailing Address
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Address Line | 307 SALEM ST
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City | ROCKTON
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State | IL
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Zip | 61072-2630
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Country | US
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Telephone | 815-624-5040
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Fax | 815-623-1691
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096.000243
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License Number State | IL
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