Healthcare Provider Details

I. General information

NPI: 1851439509
Provider Name (Legal Business Name): SHANE MATHEW COLBERG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69603 233RD STREET
DASSEL MN
55325-0002
US

IV. Provider business mailing address

PO BOX 2
DASSEL MN
55325-0002
US

V. Phone/Fax

Practice location:
  • Phone: 320-275-3730
  • Fax: 320-275-3907
Mailing address:
  • Phone: 320-275-3730
  • Fax: 320-275-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4884
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: