Healthcare Provider Details

I. General information

NPI: 1982602389
Provider Name (Legal Business Name): SHANE E ESPINOZA D.C. CCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/30/2006

III. Provider practice location address

10355 NW GLENCOE RD SUITE B
NORTH PLAINS OR
97133-8244
US

IV. Provider business mailing address

10355 NW GLENCOE RD SUITE B
NORTH PLAINS OR
97133-8244
US

V. Phone/Fax

Practice location:
  • Phone: 503-647-9944
  • Fax: 503-447-5011
Mailing address:
  • Phone: 503-647-9944
  • Fax: 503-447-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3450
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3450
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: