Provider Demographics
NPI:1164603833
Name:RAY, SHANON ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANON
Middle Name:ROBERT
Last Name:RAY
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 1:418 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-1836
Mailing Address - Country:US
Mailing Address - Phone:218-773-8403
Mailing Address - Fax:218-773-9812
Practice Address - Street 1:418 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721-1836
Practice Address - Country:US
Practice Address - Phone:218-773-8403
Practice Address - Fax:218-773-9812
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3582111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND22582OtherBC/BS
MN2086882400Medicaid
ND12129Medicaid
MN71D82RAOtherBC/BS
ND22582OtherBC/BS