Basic Information
| Provider Information | |||||||||
| NPI: | 1760727705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBBERTS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8030 OAK HILL RD NE | ||||||||
| Address2: | |||||||||
| City: | BREMEN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431079769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405032001 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 920 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW LEXINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437641552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403425161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2012 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 07400 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.