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NPI Code Detail

MEDICARE: SHANE FITNESS LLC

MEDICARE: SHANE FITNESS LLC
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
12255A2300XAthletic Trainer

General Provider Information

NPI Number : 1871108563
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHANE FITNESS LLC
Provider Business Mailing Address
First Line : 1122 WALNUT ST
Second Line :
City : YPSILANTI
State : MI
Zip : 48198-3937
Country : US
Telephone Number : 734-320-4819
Fax Number :
Provider Business Practice Location Address
First Line : 1122 WALNUT ST
Second Line :
City : YPSILANTI
State : MI
Zip : 48198-3937
Country : US
Telephone Number : 734-320-4819
Fax Number :
Authorized Official
Title or Position : ATHLETIC TRAINING
Name : MR. DELAND MAURICE MCMULLAN JR.
Credential : ATHLETIC TRAINER
Telephone Number : 734-320-4819
Provider Enumeration Date : 09/10/2020
Last Update Date : 09/10/2020

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Directions to “SHANE FITNESS LLC ” Practice Location

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