Provider Demographics
NPI:1649568734
Name:SHANNON CHIROPRACTIC WELLNESS LLC
Entity Type:Organization
Organization Name:SHANNON CHIROPRACTIC WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:518-439-1916
Mailing Address - Street 1:397 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-3248
Mailing Address - Country:US
Mailing Address - Phone:518-439-1916
Mailing Address - Fax:
Practice Address - Street 1:397 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-3248
Practice Address - Country:US
Practice Address - Phone:518-439-1916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-11
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011939261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center