Provider Demographics
NPI:1982859526
Name:SHEPPARD SPINE & SPORTS CLINIC
Entity Type:Organization
Organization Name:SHEPPARD SPINE & SPORTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:858-350-6290
Mailing Address - Street 1:634 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2422
Mailing Address - Country:US
Mailing Address - Phone:858-350-6290
Mailing Address - Fax:858-350-6775
Practice Address - Street 1:634 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2422
Practice Address - Country:US
Practice Address - Phone:858-350-6290
Practice Address - Fax:858-350-6775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16059111N00000X
CA15278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC15278Medicare UPIN
CADC16059Medicare UPIN