Provider Demographics
NPI:1124578836
Name:SMITH, SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:SMITH
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 1:12313 GOLD ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2760
Mailing Address - Country:US
Mailing Address - Phone:402-763-9015
Mailing Address - Fax:402-885-7683
Practice Address - Street 1:12313 GOLD ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2760
Practice Address - Country:US
Practice Address - Phone:402-763-9015
Practice Address - Fax:402-885-7683
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1898111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor