Provider Demographics
NPI:1568560217
Name:RIDER, SHAINE EMANUEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAINE
Middle Name:EMANUEL
Last Name:RIDER
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 1:4451 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4136
Mailing Address - Country:US
Mailing Address - Phone:337-480-0027
Mailing Address - Fax:337-480-0499
Practice Address - Street 1:4451 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4136
Practice Address - Country:US
Practice Address - Phone:337-480-0027
Practice Address - Fax:337-480-0499
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1216111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAU83569Medicare UPIN
LA4B689Medicare ID - Type Unspecified