Provider Demographics
NPI:1003849449
Name:WHITELEY, SHANE DONALD (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:DONALD
Last Name:WHITELEY
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 1:1400 SE GOLDTREE DR
Mailing Address - Street 2:# 207
Mailing Address - City:PORT ST. LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952
Mailing Address - Country:US
Mailing Address - Phone:772-777-2836
Mailing Address - Fax:772-777-2837
Practice Address - Street 1:1400 SE GOLDTREE DR
Practice Address - Street 2:# 207
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-777-2836
Practice Address - Fax:772-777-2837
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2013-05-16
Deactivation Date:2013-02-27
Deactivation Code:
Reactivation Date:2013-05-07
Provider Licenses
StateLicense IDTaxonomies
CADC26258111N00000X
FLCH10830111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU74557Medicare UPIN
CAAY620Medicare PIN