Provider Demographics
NPI:1831903905
Name:VIDAL, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:VIDAL
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 1:22003 LIGGETT ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-5721
Mailing Address - Country:US
Mailing Address - Phone:818-534-6199
Mailing Address - Fax:
Practice Address - Street 1:11260 WILBUR AVE STE 101
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91326-2450
Practice Address - Country:US
Practice Address - Phone:818-832-5656
Practice Address - Fax:818-838-5245
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53866225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant