MEDICARE: S'D'K SHOP

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
3	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1891544375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S'D'K SHOP

Provider Business Mailing Address
First Line	:	12621 HYMEADOW DR RM 331
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-2700
Country	:	US
Telephone Number	:	737-326-5315
Fax Number	:

Provider Business Practice Location Address
First Line	:	12621 HYMEADOW DR RM 331
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-2700
Country	:	US
Telephone Number	:	737-326-5315
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATONYA HOLLAND
Credential	:
Telephone Number	:	737-326-5315

Provider Enumeration Date	:	05/16/2024
Last Update Date	:	05/16/2024

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Directions to “S'D'K SHOP ” Practice Location

Language	Start Address	Practice Location

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