Provider Demographics
NPI:1306008719
Name:DR R C SHACKELFORD OPTOMETRIST
Entity Type:Organization
Organization Name:DR R C SHACKELFORD OPTOMETRIST
Other - Org Name:SHACKELFORD FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-429-4448
Mailing Address - Street 1:8815 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2312
Mailing Address - Country:US
Mailing Address - Phone:662-393-4161
Mailing Address - Fax:
Practice Address - Street 1:2350 MOUNT PLEASANT RD
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1909
Practice Address - Country:US
Practice Address - Phone:662-429-4448
Practice Address - Fax:662-429-5975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087049Medicaid
MST61215Medicare UPIN