Provider Demographics
NPI:1760874721
Name:SHELTON SPORTS AND SPINE
Entity Type:Organization
Organization Name:SHELTON SPORTS AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-904-9602
Mailing Address - Street 1:4300 PLEASANT HILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6379
Mailing Address - Country:US
Mailing Address - Phone:770-904-9602
Mailing Address - Fax:
Practice Address - Street 1:4300 PLEASANT HILL RD
Practice Address - Street 2:SUITE A
Practice Address - City:DULUTH
Practice Address - State:GEORGIA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-904-9602
Practice Address - Fax:678-401-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-01
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2081P2900X, 208VP0000X
GA059870261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty