Provider Demographics
NPI:1972273670
Name:ENRIQUEZ, SHANE MICHAEL
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:
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 7840
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92607-7840
Mailing Address - Country:US
Mailing Address - Phone:949-443-5442
Mailing Address - Fax:
Practice Address - Street 1:31271 NIGUEL RD STE J
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4135
Practice Address - Country:US
Practice Address - Phone:949-443-5442
Practice Address - Fax:949-443-5463
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51442225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant