Provider Demographics
NPI:1952811895
Name:PEACOCK, SHANNON (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:PEACOCK
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:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96160
Mailing Address - Country:US
Mailing Address - Phone:530-448-6124
Mailing Address - Fax:
Practice Address - Street 1:645 WEST LAKE BLVD. #3
Practice Address - Street 2:PO BOX 7526
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145-7526
Practice Address - Country:US
Practice Address - Phone:530-583-7475
Practice Address - Fax:530-583-7477
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34034111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor