Provider Demographics
NPI:1588387294
Name:BENALLY, SHANE (OD)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BENALLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 ISAACS AVE APT I-201
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2909
Mailing Address - Country:US
Mailing Address - Phone:901-653-5701
Mailing Address - Fax:
Practice Address - Street 1:77 WAINWRIGHT DR
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3975
Practice Address - Country:US
Practice Address - Phone:901-653-5701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100585152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist