MEDICARE: MICHAEL SHELTON

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1508604141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL SHELTON

Provider Business Mailing Address
First Line	:	908 TUOLUMNE ST
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94590-4641
Country	:	US
Telephone Number	:	707-595-0619
Fax Number	:

Provider Business Practice Location Address
First Line	:	1695 SUNSET AVE
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-4255
Country	:	US
Telephone Number	:	707-595-0619
Fax Number	:

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

Provider Enumeration Date	:	07/17/2024
Last Update Date	:	07/17/2024

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Directions to “ MICHAEL SHELTON ” Practice Location

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