Healthcare Provider Details

I. General information

NPI: 1184637373
Provider Name (Legal Business Name): PAUL SHANNON HUFFMAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 MESQUITE AVE SUITE 114
LAKE HAVASU CITY AZ
86403-5647
US

IV. Provider business mailing address

1695 MESQUITE AVE SUITE 114
LAKE HAVASU CITY AZ
86403-5647
US

V. Phone/Fax

Practice location:
  • Phone: 928-453-6808
  • Fax: 928-453-8485
Mailing address:
  • Phone: 928-453-6808
  • Fax: 928-453-8485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5112
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: