Provider Demographics
NPI:1720270523
Name:BEMO, SHAWN DALE
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DALE
Last Name:BEMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 EUFAULA AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-1132
Mailing Address - Country:US
Mailing Address - Phone:918-682-2841
Mailing Address - Fax:
Practice Address - Street 1:4009 EUFAULA AVE
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-1132
Practice Address - Country:US
Practice Address - Phone:918-682-2841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-15
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator