Provider Demographics
NPI:1528780418
Name:SHOCK KOKOMO, LLC
Entity type:Organization
Organization Name:SHOCK KOKOMO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-450-5797
Mailing Address - Street 1:15437 STAFFORDSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4644
Mailing Address - Country:US
Mailing Address - Phone:317-450-5797
Mailing Address - Fax:
Practice Address - Street 1:310 E ALTO RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3674
Practice Address - Country:US
Practice Address - Phone:765-864-2328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental