Provider Demographics
NPI:1366983397
Name:SHELDON SHADAIA
Entity type:Organization
Organization Name:SHELDON SHADAIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:MARX
Authorized Official - Last Name:SHADAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-884-3319
Mailing Address - Street 1:11941 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11941 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3004
Practice Address - Country:US
Practice Address - Phone:248-884-3319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health