Provider Demographics
NPI:1548813272
Name:SHANKS, RODERICK JOSEPH SR
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:JOSEPH
Last Name:SHANKS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 N POPPS FERRY RD # A2 & A4
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2217
Mailing Address - Country:US
Mailing Address - Phone:228-967-7991
Mailing Address - Fax:228-967-7999
Practice Address - Street 1:1636 N POPPS FERRY RD # A2 & A4
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2217
Practice Address - Country:US
Practice Address - Phone:228-967-7991
Practice Address - Fax:228-967-7999
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4505253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care