Provider Demographics
NPI:1992366223
Name:JASON SHUPE, D.O., AN OSTEOPATHIC CORPORATION
Entity Type:Organization
Organization Name:JASON SHUPE, D.O., AN OSTEOPATHIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUPE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-248-3437
Mailing Address - Street 1:554 E FOOTHILL BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1222
Mailing Address - Country:US
Mailing Address - Phone:909-248-3437
Mailing Address - Fax:844-380-6565
Practice Address - Street 1:554 E FOOTHILL BLVD STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1222
Practice Address - Country:US
Practice Address - Phone:909-248-3437
Practice Address - Fax:844-380-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty