Provider Demographics
NPI:1164598165
Name:SHEALY, MARTIN LAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LAYNE
Last Name:SHEALY
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 1:76 IRVING STREET
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-9412
Mailing Address - Fax:803-259-0559
Practice Address - Street 1:76 IRVING STREET
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812
Practice Address - Country:US
Practice Address - Phone:803-259-9412
Practice Address - Fax:803-259-0559
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2275111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
582422361OtherFEDERAL TAX ID
582422361OtherFEDERAL TAX ID