Provider Demographics
NPI:1295912723
Name:INTERSTATE CHIROPRACTIC SHAW ROBERT N & E M WAGNER PTRS
Entity type:Organization
Organization Name:INTERSTATE CHIROPRACTIC SHAW ROBERT N & E M WAGNER PTRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-621-1919
Mailing Address - Street 1:1783 MERIDEN WATERBURY TPKE
Mailing Address - Street 2:
Mailing Address - City:MILLDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06467-0475
Mailing Address - Country:US
Mailing Address - Phone:860-621-1919
Mailing Address - Fax:
Practice Address - Street 1:1783 MERIDEN WATERBURY TURNPIKE
Practice Address - Street 2:
Practice Address - City:MILLDALE
Practice Address - State:CT
Practice Address - Zip Code:06467-0475
Practice Address - Country:US
Practice Address - Phone:860-621-1919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT01066111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001066CT01OtherBC/BS LEGACY PROVIDER ID
CTC01615Medicare UPIN