Provider Demographics
NPI:1609935956
Name:WATT, M. SHANE (DC)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:SHANE
Last Name:WATT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:JARAMILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CA
Mailing Address - Street 1:1664 TOWN CENTER DR
Mailing Address - Street 2:STE D
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8697
Mailing Address - Country:US
Mailing Address - Phone:801-446-0800
Mailing Address - Fax:801-446-5351
Practice Address - Street 1:1664 W TOWN CENTER DR
Practice Address - Street 2:STE D
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8697
Practice Address - Country:US
Practice Address - Phone:801-446-0800
Practice Address - Fax:801-446-5351
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT336524-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor