Provider Demographics
NPI:1407960123
Name:HART, L. SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:L.
Middle Name:SHANE
Last Name:HART
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 1:300 W MAIN ST
Mailing Address - Street 2:P.O. BOX 308
Mailing Address - City:BOWLING GREEN
Mailing Address - State:MO
Mailing Address - Zip Code:63334-1561
Mailing Address - Country:US
Mailing Address - Phone:573-324-2225
Mailing Address - Fax:573-324-6250
Practice Address - Street 1:300 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:MO
Practice Address - Zip Code:63334-1561
Practice Address - Country:US
Practice Address - Phone:573-324-2225
Practice Address - Fax:573-324-6250
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO22424OtherBLUE CROSS BLUE SHIELD
MO22424OtherBLUE CHOICE
MO39-1886617OtherTRIAD
MO44-50040OtherUNITED HEALTH CARE
MO752706705Medicaid
MO5227583OtherAETNA
MOT43528OtherMERCY HEALTH PLANS
MO910850-633OtherFIRST HEALTH
MO22424OtherBLUE CHOICE
MO000031124Medicare ID - Type Unspecified