Basic Information
| Provider Information | |||||||||
| NPI: | 1003148503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | HALEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14960 OAK KNOLL DR | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960809410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305107067 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1860 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | RED BLUFF | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960803611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305275637 | ||||||||
| FaxNumber: | 5305270249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2010 | ||||||||
| LastUpdateDate: | 02/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | Y | Nursing Service Related Providers | Nurse's Aide |
No ID Information.