Provider Demographics
NPI:1326148313
Name:SHADE, RICHARD D (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:D
Last Name:SHADE
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 1:513 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2903
Mailing Address - Country:US
Mailing Address - Phone:843-280-7000
Mailing Address - Fax:843-280-7001
Practice Address - Street 1:513 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2903
Practice Address - Country:US
Practice Address - Phone:843-280-7000
Practice Address - Fax:843-280-7001
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010861-1111N00000X
SC2211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH414Medicaid
SCCH414Medicaid