Provider Demographics
NPI:1467522649
Name:SCOTT, SHANE M (DC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:SCOTT
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 1:10956 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3853
Mailing Address - Country:US
Mailing Address - Phone:714-798-3308
Mailing Address - Fax:714-963-5775
Practice Address - Street 1:10956 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3853
Practice Address - Country:US
Practice Address - Phone:714-798-3308
Practice Address - Fax:714-963-5775
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 24217111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33-0711373OtherTAX ID #
CADC 24217OtherDC #