Basic Information
| Provider Information | |||||||||
| NPI: | 1336804475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 383 CORBIN CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CORBIN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407011895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065262911 | ||||||||
| FaxNumber: | 6065262901 | ||||||||
| Practice Location | |||||||||
| Address1: | 1138 S HIGHWAY 27 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066772006 | ||||||||
| FaxNumber: | 6066771779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 008430 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 008430 | 01 | KY | STATE LICENSE | OTHER |