Provider Demographics
NPI:1215007760
Name:DEBOER, SHANNON LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:LEE
Last Name:DEBOER
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 1:1501 HIGHWAY 18 BYP STE B
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-9602
Mailing Address - Country:US
Mailing Address - Phone:605-745-5119
Mailing Address - Fax:605-745-3016
Practice Address - Street 1:1501 HIGHWAY 18 BYP STE B
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-9602
Practice Address - Country:US
Practice Address - Phone:605-745-5119
Practice Address - Fax:605-745-3016
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD930111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7604643Medicaid
SD7604643Medicaid