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General NPI Number Information
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NPI Number | 1215611231
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Entity Type | Individual
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Provider Name | SHILOH J BESAW L.M.T.
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Gender | Male
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Dates
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Enumeration Date | 06/12/2023
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Last Update Date | 06/12/2023
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Provider Practice Location Address
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Address Line | 1478 KENWOOD DR STE 104
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City | MENASHA
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State | WI
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Zip | 54952-1161
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Country | US
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Telephone | 920-714-9997
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Fax | 920-308-4446
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Provider Business Mailing Address
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Address Line | 1477 KENWOOD DR STE 200
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City | MENASHA
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State | WI
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Zip | 54952-1160
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Country | US
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Telephone | 920-714-9997
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Fax | 920-308-4446
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172M00000X
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Taxonomy Name | Mechanotherapist
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License Number | 15373-146
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License Number State | WI
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