Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4592 | CO |
N | 111NR0400X | Rehabilitation Chiropractor | 4592 | CO |
N | 225000000X | Orthotic Fitter | 4592 | CO |
N | 225100000X | Physical Therapist | 4592 | CO |
N | 225700000X | Massage Therapist | 4592 | CO |
NPI | 1083746614 |
---|---|
Provider Name | Dr. Shane Alan Gold |
First Address | Centennial, CO 80112-1019 |
Second Address | Centennial, CO 80122-1543 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2007 |
Last Update Date | 21/04/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U75105 | (02) | CO |