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General NPI Number Information
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NPI Number | 1811373418
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Entity Type | Individual
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Provider Name | MR. TELLY R SHELTON SR.
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Gender | Male
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Dates
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Enumeration Date | 08/05/2015
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Last Update Date | 11/09/2015
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Provider Practice Location Address
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Address Line | 7810 S EUCLID AVE 2S
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City | CHICAGO
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State | IL
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Zip | 60649-4626
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Country | US
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Telephone | 708-502-3718
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Fax |
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Provider Business Mailing Address
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Address Line | 7810 S EUCLID AVE 2S
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City | CHICAGO
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State | IL
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Zip | 60649
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Country | US
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Telephone | 708-502-3718
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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 | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | S43581676353
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License Number State | IL
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