Provider Demographics
NPI:1386418317
Name:LYNCH, SHELTON RAY
Entity type:Individual
Prefix:
First Name:SHELTON
Middle Name:RAY
Last Name:LYNCH
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 1:2907 LAKE BREEZE CT
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-3474
Mailing Address - Country:US
Mailing Address - Phone:619-993-0646
Mailing Address - Fax:
Practice Address - Street 1:2907 LAKE BREEZE CT
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-3474
Practice Address - Country:US
Practice Address - Phone:619-993-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-09
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN5292808343800000X, 347C00000X, 347E00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker