MEDICARE: S SHELBY COMMUNITY DEVELOPMENT CORPORATION

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	343900000X	Non-emergency Medical Transport (VAN)	18616798	TX
2	347C00000X	Private Vehicle	18616798	TX
3	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1932330255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S SHELBY COMMUNITY DEVELOPMENT CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 19153
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-1153
Country	:	US
Telephone Number	:	817-729-1150
Fax Number	:	817-451-2020

Provider Business Practice Location Address
First Line	:	3829 E LOOP 820 S STE 210
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4337
Country	:	US
Telephone Number	:	817-729-1150
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ MANAGER
Name	:	MS. SHALITHA RENAE SHELBY
Credential	:
Telephone Number	:	817-729-1150

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	08/04/2009

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