Provider Demographics
NPI:1255453049
Name:SHIELDS, ERIC (LVN)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 CAPALINA RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1288
Mailing Address - Country:US
Mailing Address - Phone:760-744-2104
Mailing Address - Fax:760-744-1382
Practice Address - Street 1:1560 CAPALINA RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1288
Practice Address - Country:US
Practice Address - Phone:760-744-2104
Practice Address - Fax:760-744-1382
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221297164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA221297Medicare UPIN