Provider Demographics
NPI:1104389287
Name:FLORES, SHANE ANTHONY
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ANTHONY
Last Name:FLORES
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 1:3059 ROSECREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-1156
Mailing Address - Country:US
Mailing Address - Phone:408-646-4809
Mailing Address - Fax:
Practice Address - Street 1:3059 ROSECREEK DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-1156
Practice Address - Country:US
Practice Address - Phone:408-646-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician