Healthcare Provider Details

I. General information

NPI: 1184567596
Provider Name (Legal Business Name): SHAWN COUNTRYMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W OCEAN BLVD STE 400
LONG BEACH CA
90802-4633
US

IV. Provider business mailing address

5758 GOSS RD
PHELAN CA
92371-7581
US

V. Phone/Fax

Practice location:
  • Phone: 844-982-6374
  • Fax:
Mailing address:
  • Phone: 760-536-5217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: