Provider Demographics
NPI:1790864015
Name:SHORTT, RICHARD LEO JR (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEO
Last Name:SHORTT
Suffix:JR
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 1:227 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2935
Mailing Address - Country:US
Mailing Address - Phone:770-749-8701
Mailing Address - Fax:
Practice Address - Street 1:227 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2935
Practice Address - Country:US
Practice Address - Phone:770-749-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
V07753Medicare UPIN
35ZCJLVMedicare ID - Type Unspecified