Provider Demographics
NPI:1487825212
Name:SHORT, VIP B (DC)
Entity Type:Individual
Prefix:DR
First Name:VIP
Middle Name:B
Last Name:SHORT
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 1:1448 E 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1703
Mailing Address - Country:US
Mailing Address - Phone:541-342-4476
Mailing Address - Fax:541-343-4359
Practice Address - Street 1:1448 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1703
Practice Address - Country:US
Practice Address - Phone:541-342-4476
Practice Address - Fax:541-343-4359
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117075OtherMEDICARE PTAN/LEGACY NUMB
ORR117075OtherMEDICARE PTAN/LEGACY NUMB