Healthcare Provider Details

I. General information

NPI: 1902376536
Provider Name (Legal Business Name): SHANE MICHAEL STADTMUELLER DC, MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 MAIN ST. SUITE 201
WILLIAMSVILLE NY
14221
US

IV. Provider business mailing address

5820 MAIN ST. SUITE 201
WILLIAMSVILLE NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-2587
  • Fax:
Mailing address:
  • Phone: 716-634-2587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number013177
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number013177
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number013177
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number013177
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: