Provider Demographics
NPI:1659448199
Name:SHERIDAN, SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:SHERIDAN
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 1:225 N RANCHO SANTA FE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1276
Mailing Address - Country:US
Mailing Address - Phone:760-744-0111
Mailing Address - Fax:760-744-0540
Practice Address - Street 1:225 N RANCHO SANTA FE RD STE 204
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1276
Practice Address - Country:US
Practice Address - Phone:760-744-0111
Practice Address - Fax:760-744-0540
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC27168Medicare ID - Type UnspecifiedMEDICARE ID #
CAU94697Medicare UPIN