Provider Demographics
NPI:1225399413
Name:LEWIS, SHANNON (DC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LEWIS
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:PO BOX 2229
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-0978
Mailing Address - Country:US
Mailing Address - Phone:770-813-0087
Mailing Address - Fax:770-813-9006
Practice Address - Street 1:3460 SUMMIT RIDGE PKWY STE 103
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1623
Practice Address - Country:US
Practice Address - Phone:770-813-0087
Practice Address - Fax:770-813-9006
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582521811OtherTAX IDENTIFICATION NUMBER FROM COMPLETE HEALTHCARE MEDICAL CENTER