Provider Demographics
NPI:1043025828
Name:DODGE, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:DODGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:PEETZ
Mailing Address - State:CO
Mailing Address - Zip Code:80747-0045
Mailing Address - Country:US
Mailing Address - Phone:970-466-3308
Mailing Address - Fax:
Practice Address - Street 1:925 10TH AVE
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-1609
Practice Address - Country:US
Practice Address - Phone:308-249-6728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant