Provider Demographics
NPI:1700950102
Name:SHELLY, ROBERT L (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:SHELLY
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 1:551 S E MAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-5000
Mailing Address - Country:US
Mailing Address - Phone:360-675-4954
Mailing Address - Fax:360-675-4968
Practice Address - Street 1:551 S E MAYLOR ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5000
Practice Address - Country:US
Practice Address - Phone:360-675-4954
Practice Address - Fax:360-675-4968
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0252 02 00002035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8348112Medicaid
WA91-1619092OtherFED ID #
WA0252-02 00002035OtherWA STATE LICENSE #
WA001100096Medicare ID - Type UnspecifiedMEDICARE ID #