Provider Demographics
NPI:1841319605
Name:D J SHIRLEY DC PC
Entity type:Organization
Organization Name:D J SHIRLEY DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-522-9740
Mailing Address - Street 1:2707 TOLEDO RD STE I
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-5773
Mailing Address - Country:US
Mailing Address - Phone:574-522-9740
Mailing Address - Fax:574-522-9740
Practice Address - Street 1:2707 TOLEDO RD STE I
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-5773
Practice Address - Country:US
Practice Address - Phone:574-522-9740
Practice Address - Fax:574-522-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN51000278111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200155790-AMedicaid
IN000000092311OtherANTHEM BCBS
IN184410Medicare ID - Type Unspecified
IN000000092311OtherANTHEM BCBS