Provider Demographics
NPI:1124488770
Name:SHAIN, STACIE (DOM)
Entity type:Individual
Prefix:DR
First Name:STACIE
Middle Name:
Last Name:SHAIN
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:TOME
Mailing Address - State:NM
Mailing Address - Zip Code:87060-0122
Mailing Address - Country:US
Mailing Address - Phone:505-730-1570
Mailing Address - Fax:
Practice Address - Street 1:590 BOSQUE FARMS BLVD
Practice Address - Street 2:
Practice Address - City:BOSQUE FARMS
Practice Address - State:NM
Practice Address - Zip Code:87068-9645
Practice Address - Country:US
Practice Address - Phone:505-730-1570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist