Provider Demographics
NPI:1033971577
Name:LIEDEKE, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:LIEDEKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 M 60 E
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1124 AUSTIN
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-8310
Practice Address - Country:US
Practice Address - Phone:269-228-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist