Healthcare Provider Details

I. General information

NPI: 1639094170
Provider Name (Legal Business Name): SHANE M SOVA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 US 31 S
MANISTEE MI
49660-2279
US

IV. Provider business mailing address

19520 20 MILE RD
BIG RAPIDS MI
49307-8988
US

V. Phone/Fax

Practice location:
  • Phone: 231-398-3398
  • Fax:
Mailing address:
  • Phone: 231-349-4419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number3502013351
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: