MEDICARE: MICHAEL TOREY SHACKELFORD OTR/L

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	225X00000X	Occupational Therapist	1701301	KS

General Provider Information

NPI Number	:	1871376350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL TOREY SHACKELFORD OTR/L

Provider Business Mailing Address
First Line	:	25100 W INDIAN RIDGE CT
Second Line	:
City	:	ANDALE
State	:	KS
Zip	:	67001-9741
Country	:	US
Telephone Number	:	316-617-0660
Fax Number	:

Provider Business Practice Location Address
First Line	:	9920 E HARRY ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67207-5008
Country	:	US
Telephone Number	:	316-265-4295
Fax Number	:

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

Provider Enumeration Date	:	08/17/2023
Last Update Date	:	08/17/2023

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