Provider Demographics
NPI:1851439509
Name:COLBERG, SHANE MATHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MATHEW
Last Name:COLBERG
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:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:DASSEL
Mailing Address - State:MN
Mailing Address - Zip Code:55325-0002
Mailing Address - Country:US
Mailing Address - Phone:320-275-3730
Mailing Address - Fax:320-275-3907
Practice Address - Street 1:69603 233RD STREET
Practice Address - Street 2:
Practice Address - City:DASSEL
Practice Address - State:MN
Practice Address - Zip Code:55325-0002
Practice Address - Country:US
Practice Address - Phone:320-275-3730
Practice Address - Fax:320-275-3907
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4884111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor