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General NPI Number Information
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NPI Number | 1679168637
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Entity Type | Individual
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Provider Name | SHANE G MARTIN DC
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Gender | Male
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Dates
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Enumeration Date | 03/02/2021
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 3800 S MOORLAND RD
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City | NEW BERLIN
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State | WI
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Zip | 53151-5226
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Country | US
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Telephone | 262-271-1505
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Fax |
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Provider Business Mailing Address
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Address Line | 140 COOK ST
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City | WAUKESHA
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State | WI
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Zip | 53186-4933
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Country | US
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Telephone | 262-271-1505
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Fax |
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5624-12
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License Number State | WI
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