Basic Information
| Provider Information | |||||||||
| NPI: | 1083623854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIFLEY | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 269084 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731269084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6233988072 | ||||||||
| FaxNumber: | 6233988235 | ||||||||
| Practice Location | |||||||||
| Address1: | 37591 N GANTZEL RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | SAN TAN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851407394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805908504 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 01/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7336 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 186354 | 05 | AZ | MEDICAID |