Provider Demographics
NPI:1104063775
Name:SHAW ENTERPRISES
Entity type:Organization
Organization Name:SHAW ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GEN PTR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNELLE
Authorized Official - Middle Name:NUSPL
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MSPT, DPT
Authorized Official - Phone:303-514-9912
Mailing Address - Street 1:401 RIO RANCHO WAY
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:CO
Mailing Address - Zip Code:80601-3539
Mailing Address - Country:US
Mailing Address - Phone:303-514-9912
Mailing Address - Fax:
Practice Address - Street 1:401 RIO RANCHO WAY
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:CO
Practice Address - Zip Code:80601-3539
Practice Address - Country:US
Practice Address - Phone:303-514-9912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8650261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO8650OtherCOLORADO DEPARTMENT OF REGULATORY AGENCIES