Healthcare Provider Details

I. General information

NPI: 1235288366
Provider Name (Legal Business Name): CHARLES EDWARD SHIELDS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 MOTHER LODE DR SUITE 112
SHINGLE SPRINGS CA
95682-8038
US

IV. Provider business mailing address

2256 UNIVERSITY AVE
SACRAMENTO CA
95825-7082
US

V. Phone/Fax

Practice location:
  • Phone: 530-672-8059
  • Fax: 530-672-2111
Mailing address:
  • Phone: 916-972-7875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC0108592
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: