Provider Demographics
NPI:1073903399
Name:CHIROPRACTIC CONNECTION LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC CONNECTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:SHALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-231-3457
Mailing Address - Street 1:120 S WOODLAND BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-5445
Mailing Address - Country:US
Mailing Address - Phone:386-734-1404
Mailing Address - Fax:
Practice Address - Street 1:120 S WOODLAND BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5445
Practice Address - Country:US
Practice Address - Phone:386-734-1404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-24
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty