Provider Demographics
NPI:1215229455
Name:JOE L SHACKELFORD OD LLC
Entity Type:Organization
Organization Name:JOE L SHACKELFORD OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-639-7101
Mailing Address - Street 1:1840 BRADSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-3078
Mailing Address - Country:US
Mailing Address - Phone:251-639-7101
Mailing Address - Fax:251-639-7101
Practice Address - Street 1:685 SCHILLINGER RD S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-8922
Practice Address - Country:US
Practice Address - Phone:251-633-5011
Practice Address - Fax:251-633-5394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-421-TA-151261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service