Provider Demographics
NPI:1285801936
Name:SHANE M BOGARD
Entity type:Organization
Organization Name:SHANE M BOGARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASH-CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-769-5545
Mailing Address - Street 1:PO BOX 1333
Mailing Address - Street 2:
Mailing Address - City:HAWKINS
Mailing Address - State:TX
Mailing Address - Zip Code:75765
Mailing Address - Country:US
Mailing Address - Phone:903-769-5545
Mailing Address - Fax:903-769-5945
Practice Address - Street 1:145 N BEAULAH
Practice Address - Street 2:
Practice Address - City:HAWKINS
Practice Address - State:TX
Practice Address - Zip Code:75765
Practice Address - Country:US
Practice Address - Phone:903-769-5545
Practice Address - Fax:903-769-5945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0020778-01Medicaid
TXU73595Medicare UPIN
TX5183570001Medicare NSC
TX609234Medicare PIN