Provider Demographics
NPI:1568415362
Name:SHACKELFORD, ROBERT L (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:SHACKELFORD
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 1:219 SW SECOND ST
Mailing Address - Street 2:PO BOX 896
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-2335
Mailing Address - Country:US
Mailing Address - Phone:870-886-2603
Mailing Address - Fax:870-886-2623
Practice Address - Street 1:219 SW SECOND ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-2335
Practice Address - Country:US
Practice Address - Phone:870-886-2603
Practice Address - Fax:870-886-2623
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105133718Medicaid
ART20719Medicare UPIN
AR5C384Medicare ID - Type Unspecified