Provider Demographics
NPI:1063841807
Name:SAMUEL, SHALOM (DC)
Entity Type:Individual
Prefix:DR
First Name:SHALOM
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 PROVIDENCE CMN
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-4586
Mailing Address - Country:US
Mailing Address - Phone:608-886-8568
Mailing Address - Fax:
Practice Address - Street 1:2810 CROSSROADS DR STE 4000
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8014
Practice Address - Country:US
Practice Address - Phone:608-616-4606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8352111N00000X
WI5352-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor