Provider Demographics
NPI:1518664655
Name:SHACKLEFORD, RICHARD DARYL (LMT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DARYL
Last Name:SHACKLEFORD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4463 CUMBY RD
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:AL
Mailing Address - Zip Code:35130-9196
Mailing Address - Country:US
Mailing Address - Phone:205-876-3177
Mailing Address - Fax:
Practice Address - Street 1:409 10TH AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-3630
Practice Address - Country:US
Practice Address - Phone:205-876-3177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2388225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist