Provider Demographics
NPI:1609861640
Name:SHROUT, DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:
Last Name:SHROUT
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 1:2205 HILLTOP DR
Mailing Address - Street 2:#15
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0511
Mailing Address - Country:US
Mailing Address - Phone:530-365-4369
Mailing Address - Fax:530-365-4617
Practice Address - Street 1:455 SOUTH ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2105
Practice Address - Country:US
Practice Address - Phone:530-241-2149
Practice Address - Fax:530-365-4617
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0115180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T04375Medicare UPIN
CADC0115180Medicare ID - Type Unspecified