Provider Demographics
NPI:1326142621
Name:SHELL CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:SHELL CHIROPRACTIC, LLC
Other - Org Name:SHELL FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-387-5388
Mailing Address - Street 1:3219 STERLINGTON RD.
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2519
Mailing Address - Country:US
Mailing Address - Phone:318-387-5388
Mailing Address - Fax:318-325-9882
Practice Address - Street 1:3219 STERLINGTON RD.
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2519
Practice Address - Country:US
Practice Address - Phone:318-387-5388
Practice Address - Fax:318-325-9882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA805111N00000X
LA1002111N00000X
LA1397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA59489Medicare ID - Type Unspecified
T69657Medicare UPIN