Provider Demographics
NPI:1538884697
Name:SHOAL CREEK FOOT AND ANKLE CENTER LLC
Entity type:Organization
Organization Name:SHOAL CREEK FOOT AND ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:SEDBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-622-0648
Mailing Address - Street 1:1801 W 32ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1528
Mailing Address - Country:US
Mailing Address - Phone:417-622-0648
Mailing Address - Fax:
Practice Address - Street 1:4136 S MCCANN CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7253
Practice Address - Country:US
Practice Address - Phone:417-755-7612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-11
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty