Provider Demographics
NPI:1245638808
Name:REILLY, SHANE (ATC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13128 CONCORD DR W
Mailing Address - Street 2:
Mailing Address - City:LILLIAN
Mailing Address - State:AL
Mailing Address - Zip Code:36549-3960
Mailing Address - Country:US
Mailing Address - Phone:850-884-4661
Mailing Address - Fax:
Practice Address - Street 1:100 SERVAIS WAY
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32566
Practice Address - Country:US
Practice Address - Phone:850-884-4661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL32502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer