Provider Demographics
NPI:1609906866
Name:SHALLOW, RANDY JOE (CHIROPRACTIC)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:JOE
Last Name:SHALLOW
Suffix:
Gender:M
Credentials:CHIROPRACTIC
Other - Prefix:DR
Other - First Name:RANDY
Other - Middle Name:JOE
Other - Last Name:SHALLOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHIROPRACTOR
Mailing Address - Street 1:24820 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1713
Mailing Address - Country:US
Mailing Address - Phone:313-277-3766
Mailing Address - Fax:
Practice Address - Street 1:24820 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1713
Practice Address - Country:US
Practice Address - Phone:313-277-3766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q25207Medicare ID - Type Unspecified