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General NPI Number Information
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NPI Number | 1649869264
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Entity Type | Individual
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Provider Name | SHAJUAN VIRGIL C.PED., LMT
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Gender | Female
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Dates
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Enumeration Date | 01/18/2021
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Last Update Date | 01/18/2021
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Provider Practice Location Address
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Address Line | 108 BAYTREE DR
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City | THOMASVILLE
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State | GA
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Zip | 31792-8861
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Country | US
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Telephone | 678-682-4493
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2428
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City | ACWORTH
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State | GA
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Zip | 30102-0008
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Country | US
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Telephone | 678-682-4493
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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 | 224L00000X
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Taxonomy Name | Pedorthist
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License Number | CPED4585
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT001526
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License Number State | GA
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