Provider Demographics
NPI:1619037033
Name:TROUMBLEY, SHENANDOAH LAYNE (DC CNIM)
Entity Type:Individual
Prefix:MR
First Name:SHENANDOAH
Middle Name:LAYNE
Last Name:TROUMBLEY
Suffix:
Gender:M
Credentials:DC CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 S 300 E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1318
Mailing Address - Country:US
Mailing Address - Phone:734-545-3896
Mailing Address - Fax:
Practice Address - Street 1:43 S 300 E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1318
Practice Address - Country:US
Practice Address - Phone:734-545-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1091111N00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806965100Medicaid
ID000010148066OtherBLUE SHEILD OF IDAHO
IDC4785OtherBLUE CROSS OF IDAHO
ID806965100Medicaid
ID1675575Medicare ID - Type Unspecified
ID806965100Medicaid