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General NPI Number Information
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NPI Number | 1548868474
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Entity Type | Individual
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Provider Name | SHANE EDWARD BRAGG
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Gender | Male
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Dates
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Enumeration Date | 10/13/2020
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Last Update Date | 01/09/2023
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Provider Practice Location Address
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Address Line | 1520 IRISH MTN RD
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City | SHADY SPRING
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State | WV
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Zip | 25918
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Country | US
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Telephone | 304-222-1156
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2091
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City | BEAVER
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State | WV
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Zip | 25813-2091
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Country | US
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Telephone | 304-222-1156
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Fax |
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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 | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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