Provider Demographics
NPI:1356350672
Name:RUBY, SHANNON
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:RUBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1976 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-7801
Mailing Address - Country:US
Mailing Address - Phone:847-730-3276
Mailing Address - Fax:847-730-3972
Practice Address - Street 1:1976 TOWER DR
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-7801
Practice Address - Country:US
Practice Address - Phone:847-730-3276
Practice Address - Fax:847-730-3972
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009967111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009967OtherSATE LICENSE
IL038009967OtherSATE LICENSE