Provider Demographics
NPI:1518663053
Name:SHANE LLC
Entity Type:Organization
Organization Name:SHANE LLC
Other - Org Name:PINETREE LANE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-403-9372
Mailing Address - Street 1:15427 BLACK CYN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-4015
Mailing Address - Country:US
Mailing Address - Phone:210-403-9372
Mailing Address - Fax:
Practice Address - Street 1:2002 PINETREE LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-4938
Practice Address - Country:US
Practice Address - Phone:210-403-9372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-06
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities