Provider Demographics
NPI:1770644908
Name:BLADEL, SHAWN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:MICHAEL
Last Name:BLADEL
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 1:329 AMPHITHEATER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6662
Mailing Address - Country:US
Mailing Address - Phone:779-210-3994
Mailing Address - Fax:
Practice Address - Street 1:329 AMPHITHEATER DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6662
Practice Address - Country:US
Practice Address - Phone:779-210-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.010820111N00000X
IL038010820111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038.010820OtherSTATE OF ILLINOIS LICENSE