Provider Demographics
NPI:1336340314
Name:SHADOW MOUNTAIN CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:SHADOW MOUNTAIN CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:970-887-3131
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:GRANBY
Mailing Address - State:CO
Mailing Address - Zip Code:80446-0036
Mailing Address - Country:US
Mailing Address - Phone:970-887-3131
Mailing Address - Fax:970-887-3913
Practice Address - Street 1:60 SECOND ST
Practice Address - Street 2:
Practice Address - City:GRANBY
Practice Address - State:CO
Practice Address - Zip Code:80446-0036
Practice Address - Country:US
Practice Address - Phone:970-887-3131
Practice Address - Fax:970-887-3913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty