MEDICARE: DR. JARED MARK SHELTON DC, BS, CSCS

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	111N00000X	Chiropractor	CHIA-1284	ID
2	111NS0005X	Sports Physician Chiropractor	CHIA-1284	ID

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	1673568	OTHER	ID	MEDICARE INDIVIDUAL PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457537862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JARED MARK SHELTON DC, BS, CSCS

Provider Business Mailing Address
First Line	:	45 W CENTER ST
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1530
Country	:	US
Telephone Number	:	208-547-4518
Fax Number	:	208-547-4555

Provider Business Practice Location Address
First Line	:	45 W CENTER ST
Second Line	:
City	:	SODA SPRINGS
State	:	ID
Zip	:	83276-1530
Country	:	US
Telephone Number	:	208-547-4518
Fax Number	:	208-547-4555

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

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	09/03/2008

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