Active NPI
Shane Sullaway
- Other Technician
- Grand Prairie, TX
National Provider Identifier
1366738320
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Other Technician
- Practice address
- 2100 N Highway 360
Ste. 1802
Grand Prairie, TX 75050-1011 - Phone
- (972) 647-8567
- Fax
- (972) 660-4548
- NPI assigned
- Jun 28, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Other Technician | 247200000X | Primary |
Addresses
Primary practice location
2100 N Highway 360
Ste. 1802
Grand Prairie, TX 75050-1011
Mailing address
2100 N Highway 360
Ste. 1802
Grand Prairie, TX 75050-1011
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 247200000X | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Amigo Mobility Center Inc. | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Customized Equipment (DME)
- Grand Prairie, TX
- NPI 1720026198
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1309219200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1309219200000",
"number": "1366738320",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2100 N HIGHWAY 360",
"address_2": "STE. 1802",
"city": "GRAND PRAIRIE",
"state": "TX",
"postal_code": "750501011"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2100 N HIGHWAY 360",
"address_2": "STE. 1802",
"city": "GRAND PRAIRIE",
"state": "TX",
"postal_code": "750501011",
"telephone_number": "972-647-8567",
"fax_number": "972-660-4548"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLAWAY",
"first_name": "SHANE",
"name_prefix": "Mr.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-06-28",
"last_updated": "2011-06-28",
"status": "A"
},
"taxonomies": [
{
"code": "247200000X",
"taxonomy_group": "",
"desc": "Technician, Other",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "247200000X",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Grand Prairie, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 28, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.