Provider Demographics
NPI:1215000278
Name:SHIRLEY CHIROPRACTIC & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SHIRLEY CHIROPRACTIC & WELLNESS CENTER, LLC
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-772-7626
Mailing Address - Street 1:612 SAINT ANDREWS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-5120
Mailing Address - Country:US
Mailing Address - Phone:803-772-7626
Mailing Address - Fax:
Practice Address - Street 1:612 SAINT ANDREWS RD STE 3
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-5120
Practice Address - Country:US
Practice Address - Phone:803-772-7626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2245111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2245Medicaid
SCCH2245Medicaid
SCU9444677890Medicare ID - Type Unspecified