Sullaway, Shane

Sullaway, Shane is an individual health care provider with primary practice located at 2100 N Highway 360 Ste. 1802, Grand Prairie TX 75050-1011. He recently has only one registered license in Technologists, Technicians & Other Technical Service Providers / Technician, Other, which is considered as his primary health care specialty. Sullaway, Shane can be contacted via phone (972) 647-8567.

Contact Information

Primary practice address
2100 N Highway 360 Ste. 1802 Grand Prairie TX 75050-1011
Phone: (972) 647-8567
Fax: (972) 660-4548
Website:
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Health care specialties

SpecialtyCodeLicense #State
Technologists, Technicians & Other Technical Service Providers / Technician, Other 247200000X

Profile Details

NPI number 1366738320
LBN Legal business name Sullaway, Shane
Credentials
Entity Individual
Sole proprietor 1 No
Enumeration date Jun 28th, 2011
Last updated Jun 28th, 2011 - about 15 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1366738320 NPPES
Texas MEDICAID 247200000X

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