Provider Demographics
NPI:1669120101
Name:SHANNON, SPENCER LEE (DC)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:LEE
Last Name:SHANNON
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 1:320 WABASH CIR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:IN
Mailing Address - Zip Code:47610-9387
Mailing Address - Country:US
Mailing Address - Phone:870-349-4344
Mailing Address - Fax:
Practice Address - Street 1:7125 HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:WADESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47638-9635
Practice Address - Country:US
Practice Address - Phone:812-637-4947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003282A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor