Healthcare Provider Details

I. General information

NPI: 1811142086
Provider Name (Legal Business Name): MR. SHANE WESLEY CLEMENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7609 ALBERT RD
SAGINAW MN
55779-9676
US

IV. Provider business mailing address

7609 ALBERT RD
SAGINAW MN
55779-9676
US

V. Phone/Fax

Practice location:
  • Phone: 218-390-6415
  • Fax:
Mailing address:
  • Phone: 218-390-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: