Provider Demographics
NPI:1407886930
Name:BOGARD, SHANE M
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:BOGARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1333
Mailing Address - Street 2:
Mailing Address - City:HAWKINS
Mailing Address - State:TX
Mailing Address - Zip Code:75765-1333
Mailing Address - Country:US
Mailing Address - Phone:903-769-5545
Mailing Address - Fax:903-769-5945
Practice Address - Street 1:145 N BEAULAH
Practice Address - Street 2:
Practice Address - City:HAWKINS
Practice Address - State:TX
Practice Address - Zip Code:75765
Practice Address - Country:US
Practice Address - Phone:903-769-5545
Practice Address - Fax:903-769-5945
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0020778-01Medicaid
TX0020778-01Medicaid
TX609234Medicare PIN
TXU73595Medicare UPIN