Provider Demographics
NPI:1871108563
Name:SHANE FITNESS LLC
Entity type:Organization
Organization Name:SHANE FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINING
Authorized Official - Prefix:MR
Authorized Official - First Name:DELAND
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:MCMULLAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:ATHLETIC TRAINER
Authorized Official - Phone:734-320-4819
Mailing Address - Street 1:1122 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3937
Mailing Address - Country:US
Mailing Address - Phone:734-320-4819
Mailing Address - Fax:
Practice Address - Street 1:1122 WALNUT ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-3937
Practice Address - Country:US
Practice Address - Phone:734-320-4819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty