=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992366223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JASON SHUPE, D.O., AN OSTEOPATHIC CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2019
-----------------------------------------------------
Last Update Date | 06/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 554 E FOOTHILL BLVD STE 120
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-248-3437
-----------------------------------------------------
Fax | 844-380-6565
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 554 E FOOTHILL BLVD STE 120
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-248-3437
-----------------------------------------------------
Fax | 844-380-6565
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JASON SHUPE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 909-248-3437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------