Provider Demographics
NPI:1881829497
Name:LACAILLADE, SHANE A (IDMT)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:A
Last Name:LACAILLADE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 SHAMROCK CT
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-2490
Mailing Address - Country:US
Mailing Address - Phone:660-747-3477
Mailing Address - Fax:
Practice Address - Street 1:331 SIJAN AVE
Practice Address - Street 2:
Practice Address - City:WHITEMAN AFB
Practice Address - State:MO
Practice Address - Zip Code:65305-1269
Practice Address - Country:US
Practice Address - Phone:660-687-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians