Provider Demographics
NPI:1184315079
Name:BREHM, SHELBY DIANNE (LDO)
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:DIANNE
Last Name:BREHM
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 LEXINGTON RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-2525
Mailing Address - Country:US
Mailing Address - Phone:706-355-3142
Mailing Address - Fax:706-355-3820
Practice Address - Street 1:4375 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2525
Practice Address - Country:US
Practice Address - Phone:706-355-3142
Practice Address - Fax:706-355-3820
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1402156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician