Provider Demographics
NPI:1295812154
Name:WEATHERFORD, MICHAEL SHANNON (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHANNON
Last Name:WEATHERFORD
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 1:1105 48TH AVE N
Mailing Address - Street 2:SUITE 106
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5419
Mailing Address - Country:US
Mailing Address - Phone:843-497-5197
Mailing Address - Fax:
Practice Address - Street 1:1105 48TH AVE N
Practice Address - Street 2:SUITE 106
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5419
Practice Address - Country:US
Practice Address - Phone:843-497-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2567111N00000X
NC2980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2567Medicaid