Provider Demographics
NPI:1699319558
Name:SHELBY MEDICAL, INC.
Entity type:Organization
Organization Name:SHELBY MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-213-2546
Mailing Address - Street 1:102 N 17TH ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AR
Mailing Address - Zip Code:72949-2349
Mailing Address - Country:US
Mailing Address - Phone:479-213-2546
Mailing Address - Fax:
Practice Address - Street 1:11 SHERWOOD LN
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-4500
Practice Address - Country:US
Practice Address - Phone:479-213-2546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty