Provider Demographics
NPI:1215611231
Name:BESAW, SHILOH J (LMT)
Entity type:Individual
Prefix:
First Name:SHILOH
Middle Name:J
Last Name:BESAW
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 KENWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-1160
Mailing Address - Country:US
Mailing Address - Phone:920-714-9997
Mailing Address - Fax:920-308-4446
Practice Address - Street 1:1478 KENWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1161
Practice Address - Country:US
Practice Address - Phone:920-714-9997
Practice Address - Fax:920-308-4446
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15373-146172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist