=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548813272
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RODERICK JOSEPH SHANKS SR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 07/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1636 N POPPS FERRY RD # A2 & A4
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-967-7991
-----------------------------------------------------
Fax | 228-967-7999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1636 N POPPS FERRY RD # A2 & A4
-----------------------------------------------------
City | BILOXI
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39532-2217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-967-7991
-----------------------------------------------------
Fax | 228-967-7999
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 4505
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------