Provider Demographics
NPI:1558955328
Name:SHELLBACK ENTERPRISE CORPORATION
Entity Type:Organization
Organization Name:SHELLBACK ENTERPRISE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ADAIR
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-873-2972
Mailing Address - Street 1:PO BOX 2034
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-2034
Mailing Address - Country:US
Mailing Address - Phone:770-338-6799
Mailing Address - Fax:678-442-6440
Practice Address - Street 1:170 CAMDEN HILL RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7418
Practice Address - Country:US
Practice Address - Phone:770-338-6799
Practice Address - Fax:770-338-6799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251E00000XAgenciesHome Health
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies