Provider Demographics
NPI:1144324161
Name:SHANE, WOLFGANG (DC)
Entity type:Individual
Prefix:DR
First Name:WOLFGANG
Middle Name:
Last Name:SHANE
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 1:20803 VALLEY BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-2572
Mailing Address - Country:US
Mailing Address - Phone:909-468-4947
Mailing Address - Fax:909-598-2011
Practice Address - Street 1:20803 VALLEY BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-2572
Practice Address - Country:US
Practice Address - Phone:909-598-2111
Practice Address - Fax:909-598-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22646111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU47735Medicare UPIN