Provider Demographics
NPI:1265060420
Name:SHD CLINICAL SERVICES
Entity type:Organization
Organization Name:SHD CLINICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES-DOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:901-483-7268
Mailing Address - Street 1:3856 CHANDLER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4295 CHILDS DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-6909
Practice Address - Country:US
Practice Address - Phone:901-483-5791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-31
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No253Z00000XAgenciesIn Home Supportive Care
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3341212Medicaid