1649397928 NPI number — MR. SHANE EDWARD THERIAULT LSW-C

Table of content: MR. SHANE EDWARD THERIAULT LSW-C (NPI 1649397928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649397928 NPI number — MR. SHANE EDWARD THERIAULT LSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THERIAULT
Provider First Name:
SHANE
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LSW-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649397928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24 COOLIDGE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARIBOU
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04736-2406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-493-1067
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 LOMBARD RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARIBOU
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04736-0748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-498-2575
Provider Business Practice Location Address Fax Number:
207-492-2410
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LSX8780 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LSX8780 . This is a "LISCENSE NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com