Provider Demographics
NPI:1609948397
Name:SHUTTLEWORTH CHIROPRACTIC CENTRE PA
Entity Type:Organization
Organization Name:SHUTTLEWORTH CHIROPRACTIC CENTRE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHUTTLEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:228-896-3002
Mailing Address - Street 1:665 EAST PASS RD STE 3
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507
Mailing Address - Country:US
Mailing Address - Phone:228-896-3002
Mailing Address - Fax:228-897-1417
Practice Address - Street 1:665 EAST PASS RD STE 3
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507
Practice Address - Country:US
Practice Address - Phone:228-896-3002
Practice Address - Fax:228-897-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115351Medicaid
T21167Medicare UPIN
MS00115351Medicaid