Provider Demographics
NPI:1417449901
Name:SHATTO, STEFEN FOX (L AC)
Entity Type:Individual
Prefix:
First Name:STEFEN
Middle Name:FOX
Last Name:SHATTO
Suffix:
Gender:M
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 FORUM BLVD STE B2
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6343
Mailing Address - Country:US
Mailing Address - Phone:573-833-4296
Mailing Address - Fax:
Practice Address - Street 1:2600 FORUM BLVD STE B2
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6343
Practice Address - Country:US
Practice Address - Phone:573-833-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017044204171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist