Healthcare Provider Details

I. General information

NPI: 1750949418
Provider Name (Legal Business Name): SHANE ALAN FAHRNOW LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LOGAN AVE. SUITE B
TERRY MT
59349
US

IV. Provider business mailing address

PO BOX 235
FALLON MT
59326-0235
US

V. Phone/Fax

Practice location:
  • Phone: 406-939-4818
  • Fax:
Mailing address:
  • Phone: 406-939-4818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1441
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: