Provider Demographics
NPI:1972732857
Name:DR PAMELA SHACKLEY DC PA
Entity Type:Organization
Organization Name:DR PAMELA SHACKLEY DC PA
Other - Org Name:ADVANCED CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-955-6080
Mailing Address - Street 1:1217 S EAST AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2344
Mailing Address - Country:US
Mailing Address - Phone:941-955-6080
Mailing Address - Fax:941-957-1142
Practice Address - Street 1:1217 S EAST AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2344
Practice Address - Country:US
Practice Address - Phone:941-955-6080
Practice Address - Fax:941-957-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3820050-00Medicaid
88735AMedicare PIN