Provider Demographics
NPI:1407948094
Name:SHKOLNIKOV, LEO (DC)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:SHKOLNIKOV
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 1:1110 W SHORE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-4054
Mailing Address - Country:US
Mailing Address - Phone:214-575-8811
Mailing Address - Fax:
Practice Address - Street 1:1110 W SHORE DR
Practice Address - Street 2:SUITE F
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-4054
Practice Address - Country:US
Practice Address - Phone:214-575-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9931111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV03645Medicare UPIN
TX8D1858Medicare ID - Type Unspecified