Provider Demographics
NPI:1477810745
Name:SHELTON, RONALD P (AT,C/L)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:P
Last Name:SHELTON
Suffix:
Gender:M
Credentials:AT,C/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 SALEM ST
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2630
Mailing Address - Country:US
Mailing Address - Phone:815-624-5040
Mailing Address - Fax:815-623-1691
Practice Address - Street 1:4675 BLUESTEM RD # 1
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-7788
Practice Address - Country:US
Practice Address - Phone:815-623-9930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0002432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer