Provider Demographics
NPI:1811226780
Name:RED SHIRT, CARMEL (LPN)
Entity Type:Individual
Prefix:
First Name:CARMEL
Middle Name:
Last Name:RED SHIRT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CANYON LAKE DR.
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-8197
Mailing Address - Country:US
Mailing Address - Phone:605-355-2500
Mailing Address - Fax:
Practice Address - Street 1:3200 CANYON LAKE DR.
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8197
Practice Address - Country:US
Practice Address - Phone:605-355-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDP007378164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0140070Medicaid
SD5549050Medicaid
SD0140070Medicaid
SDHSZ050Medicare PIN
SD430082Medicare Oscar/Certification