Provider Demographics
NPI:1639789340
Name:SHANTISE MICHELLE LLC
Entity Type:Organization
Organization Name:SHANTISE MICHELLE LLC
Other - Org Name:SHANTISE MICHELLE CRANIAL PROSTHESIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANTISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-901-3640
Mailing Address - Street 1:2040 MILLBURN AVE STE 305
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3716
Mailing Address - Country:US
Mailing Address - Phone:973-901-3640
Mailing Address - Fax:
Practice Address - Street 1:2040 MILLBURN AVE STE 305
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3716
Practice Address - Country:US
Practice Address - Phone:973-901-3640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier