Provider Demographics
NPI:1710988068
Name:SHALLOW CHIROPRACTIC PC
Entity Type:Organization
Organization Name:SHALLOW CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:SHALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-277-3766
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:313-277-7196
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:313-277-7196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRS004116OtherBCBS
MIT33862Medicare ID - Type Unspecified