Provider Demographics
NPI:1922003979
Name:SHAW, EARL WILSON (DC)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:WILSON
Last Name:SHAW
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 1:26810 YNEZ CT STE D
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-4691
Mailing Address - Country:US
Mailing Address - Phone:951-695-1176
Mailing Address - Fax:
Practice Address - Street 1:27536 YNEZ RD
Practice Address - Street 2:STE F19
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4665
Practice Address - Country:US
Practice Address - Phone:951-695-1176
Practice Address - Fax:951-695-2096
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0138690Medicare UPIN