Provider Demographics
NPI:1194890673
Name:SHANNON R. CHANDLER, CORP
Entity type:Organization
Organization Name:SHANNON R. CHANDLER, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-791-6860
Mailing Address - Street 1:3962 BLUE DIAMOND RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7795
Mailing Address - Country:US
Mailing Address - Phone:702-791-6860
Mailing Address - Fax:702-791-7028
Practice Address - Street 1:3962 BLUE DIAMOND RD STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7795
Practice Address - Country:US
Practice Address - Phone:702-791-6068
Practice Address - Fax:702-791-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU99200Medicare UPIN
NV38720Medicare ID - Type Unspecified