Provider Demographics
NPI:1265026322
Name:COUNTRYMAN, SHANE JEFFERY (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:JEFFERY
Last Name:COUNTRYMAN
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 1:5149 PRUITT DR
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-1234
Mailing Address - Country:US
Mailing Address - Phone:972-469-2976
Mailing Address - Fax:
Practice Address - Street 1:4190 N GARFIELD AVE # 2
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-2241
Practice Address - Country:US
Practice Address - Phone:972-469-2976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR.0008243111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor