MEDICARE: SHAWN A KIRK B.O.C.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1508276775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN A KIRK B.O.C.P.

Provider Business Mailing Address
First Line	:	2231 E MILLBROOK RD
Second Line	:	101
City	:	RALEIGH
State	:	NC
Zip	:	27604-1746
Country	:	US
Telephone Number	:	919-510-4131
Fax Number	:	919-510-4132

Provider Business Practice Location Address
First Line	:	2231 E MILLBROOK RD
Second Line	:	101
City	:	RALEIGH
State	:	NC
Zip	:	27604-1746
Country	:	US
Telephone Number	:	919-510-4131
Fax Number	:	919-510-4132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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