Provider Demographics
NPI:1740929256
Name:SHADOW CHIROPRACTIC INC
Entity type:Organization
Organization Name:SHADOW CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGALA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-968-9371
Mailing Address - Street 1:23077 GREENFIELD RD STE 158
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 158
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3765
Practice Address - Country:US
Practice Address - Phone:248-782-5582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty