Provider Demographics
NPI:1346389582
Name:HINCKLEY, SHANE MARTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MARTIN
Last Name:HINCKLEY
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 1:150 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3620
Mailing Address - Country:US
Mailing Address - Phone:601-684-9200
Mailing Address - Fax:
Practice Address - Street 1:150 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3620
Practice Address - Country:US
Practice Address - Phone:601-684-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS640923144111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125195Medicaid
MS00125195Medicaid
MS350000296Medicare ID - Type Unspecified