Provider Demographics
NPI:1497371520
Name:RACHAL, SHELLEY CLARK (OD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:CLARK
Last Name:RACHAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 MAXWELL CIR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:CO
Mailing Address - Zip Code:80516-8409
Mailing Address - Country:US
Mailing Address - Phone:630-532-4998
Mailing Address - Fax:
Practice Address - Street 1:6800 N 79TH ST STE 101
Practice Address - Street 2:
Practice Address - City:NIWOT
Practice Address - State:CO
Practice Address - Zip Code:80503-8978
Practice Address - Country:US
Practice Address - Phone:303-652-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003731152WV0400X
NY009228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy