Provider Demographics
NPI:1750949418
Name:FAHRNOW, SHANE ALAN (LMT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:ALAN
Last Name:FAHRNOW
Suffix:
Gender:M
Credentials:LMT
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 235
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:MT
Mailing Address - Zip Code:59326-0235
Mailing Address - Country:US
Mailing Address - Phone:406-939-4818
Mailing Address - Fax:
Practice Address - Street 1:204 LOGAN AVE.
Practice Address - Street 2:SUITE B
Practice Address - City:TERRY
Practice Address - State:MT
Practice Address - Zip Code:59349
Practice Address - Country:US
Practice Address - Phone:406-939-4818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist