Provider Demographics
NPI:1598301020
Name:MANCUSO, SHANTAI IRENE (DC, BSC)
Entity Type:Individual
Prefix:DR
First Name:SHANTAI
Middle Name:IRENE
Last Name:MANCUSO
Suffix:
Gender:F
Credentials:DC, BSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9090 RIDGELINE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2505
Mailing Address - Country:US
Mailing Address - Phone:303-683-9494
Mailing Address - Fax:
Practice Address - Street 1:9090 RIDGELINE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-2505
Practice Address - Country:US
Practice Address - Phone:303-683-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2024-01-31
Deactivation Date:2019-12-10
Deactivation Code:
Reactivation Date:2019-12-20
Provider Licenses
StateLicense IDTaxonomies
COCHR-0008097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor