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NPI Code Detail

MEDICARE: SHANA THEDFORD RO

MEDICARE: SHANA THEDFORD RO
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
1156FX1800XOpticianMS
2156FX1101XOphthalmic Assistant
3156FC0800XContact Lens Technician/TechnologistMS
4156FX1700XOcularist
5156FX1101XOphthalmic AssistantMS
6171400000XHealth & Wellness CoachMS

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
216999022OTHERNCCERTIFIED CHILDREN'S VISION SCREENER

General Provider Information

NPI Number : 1790289510
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANA THEDFORD RO
Provider Business Mailing Address
First Line : 3220 LAUDERDALE RD
Second Line :
City : LAUDERDALE
State : MS
Zip : 39335-9639
Country : US
Telephone Number : 601-616-1210
Fax Number : 601-483-7983
Provider Business Practice Location Address
First Line : 3304 8TH ST
Second Line :
City : MERIDIAN
State : MS
Zip : 39301-4755
Country : US
Telephone Number : 844-225-7160
Fax Number : 386-343-7195
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/19/2018
Last Update Date : 01/14/2026

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Directions to “ SHANA THEDFORD RO” Practice Location

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