MEDICARE: SHANE ANTHONY FLORES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1104389287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE ANTHONY FLORES

Provider Business Mailing Address
First Line	:	3059 ROSECREEK DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95148-1156
Country	:	US
Telephone Number	:	408-646-4809
Fax Number	:

Provider Business Practice Location Address
First Line	:	3059 ROSECREEK DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95148-1156
Country	:	US
Telephone Number	:	408-646-4809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2019
Last Update Date	:	04/07/2019

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Directions to “ SHANE ANTHONY FLORES ” Practice Location

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