Provider Demographics
NPI:1467522649
Name:SCOTT, SHANE M (DC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13071 BROOKHURST ST STE 110
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1047
Mailing Address - Country:US
Mailing Address - Phone:714-839-8144
Mailing Address - Fax:714-908-2328
Practice Address - Street 1:13071 BROOKHURST ST STE 110
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1047
Practice Address - Country:US
Practice Address - Phone:714-839-8144
Practice Address - Fax:714-908-2328
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 24217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0711373OtherTAX ID #
CADC 24217OtherDC #