Provider Demographics
NPI:1467160739
Name:RADIE RAE'S SHIRT SHACK
Entity Type:Organization
Organization Name:RADIE RAE'S SHIRT SHACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:RCP
Authorized Official - Phone:910-740-7495
Mailing Address - Street 1:703 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3458
Mailing Address - Country:US
Mailing Address - Phone:910-740-7495
Mailing Address - Fax:
Practice Address - Street 1:703 W 26TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3458
Practice Address - Country:US
Practice Address - Phone:910-740-7495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedGroup - Single Specialty