Provider Demographics
NPI:1174284228
Name:SHEA, JOHN J
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:SHEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LIGHTHOUSE LN STE 919
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-2941
Mailing Address - Country:US
Mailing Address - Phone:843-592-2868
Mailing Address - Fax:
Practice Address - Street 1:2 LIGHTHOUSE LN STE 919
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29928-2941
Practice Address - Country:US
Practice Address - Phone:843-592-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-31
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
No251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty