Provider Demographics
NPI:1366586836
Name:SHEA, DANIEL THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:SHEA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1452
Mailing Address - Country:US
Mailing Address - Phone:231-796-3935
Mailing Address - Fax:231-796-3510
Practice Address - Street 1:621 N STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1452
Practice Address - Country:US
Practice Address - Phone:231-796-3935
Practice Address - Fax:231-796-3510
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33245Medicare UPIN
MIOE45000Medicare ID - Type Unspecified