Provider Demographics
NPI:1760741813
Name:OGLE, SHANE R (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:R
Last Name:OGLE
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 1:103 ICHORD AVE
Mailing Address - Street 2:STE B
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-5402
Mailing Address - Country:US
Mailing Address - Phone:417-532-9166
Mailing Address - Fax:
Practice Address - Street 1:464 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-2742
Practice Address - Country:US
Practice Address - Phone:417-532-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012013169111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor