=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588928790
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELBY MACKINTOSH ALLEY DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2012
-----------------------------------------------------
Last Update Date | 08/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10535 HOSPITAL WAY
-----------------------------------------------------
City | MATHER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95655-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-843-7151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10535 HOSPITAL WAY
-----------------------------------------------------
City | MATHER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95655-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-330-4114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | T-1239
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | E5181
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------