Provider Demographics
NPI:1366645061
Name:SHANNON, STORM W (DC, ATC)
Entity Type:Individual
Prefix:DR
First Name:STORM
Middle Name:W
Last Name:SHANNON
Suffix:
Gender:M
Credentials:DC, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 E REPUBLIC RD
Mailing Address - Street 2:STE I
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6549
Mailing Address - Country:US
Mailing Address - Phone:417-877-9404
Mailing Address - Fax:417-877-9408
Practice Address - Street 1:1730 E REPUBLIC RD
Practice Address - Street 2:STE I
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6549
Practice Address - Country:US
Practice Address - Phone:417-877-9404
Practice Address - Fax:417-877-9408
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007014598111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor