Provider Demographics
NPI:1235288366
Name:SHIELDS, CHARLES EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWARD
Last Name:SHIELDS
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 1:2256 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-7082
Mailing Address - Country:US
Mailing Address - Phone:916-972-7875
Mailing Address - Fax:
Practice Address - Street 1:4140 MOTHER LODE DR
Practice Address - Street 2:SUITE 112
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8038
Practice Address - Country:US
Practice Address - Phone:530-672-8059
Practice Address - Fax:530-672-2111
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0108592111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP70630FMedicaid
CADC0108592OtherCHIROPRATIC LICENSE NUMBE
CADC0108592OtherCHIROPRATIC LICENSE NUMBE