Provider Demographics
NPI:1891396834
Name:SHINE FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:SHINE FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:512-705-7737
Mailing Address - Street 1:11614 FM 2244 RD STE 150
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78738-5471
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11614 FM 2244 RD STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738-5471
Practice Address - Country:US
Practice Address - Phone:512-705-7737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty