MEDICARE: MR. SHELWYN L SHACKLEFORD

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	347C00000X	Private Vehicle	PGR-6868	TX

General Provider Information

NPI Number	:	1962110999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SHELWYN L SHACKLEFORD

Provider Business Mailing Address
First Line	:	14011 CATINA LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77045-5109
Country	:	US
Telephone Number	:	832-545-0562
Fax Number	:

Provider Business Practice Location Address
First Line	:	14011 CATINA LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77045-5109
Country	:	US
Telephone Number	:	832-545-0562
Fax Number	:

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

Provider Enumeration Date	:	11/08/2022
Last Update Date	:	11/08/2022

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Directions to “ MR. SHELWYN L SHACKLEFORD ” Practice Location

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