Healthcare Provider Details

I. General information

NPI: 1225399413
Provider Name (Legal Business Name): SHANNON LEWIS D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3460 SUMMIT RIDGE PKWY STE 103
DULUTH GA
30096-1623
US

IV. Provider business mailing address

PO BOX 2229
SUWANEE GA
30024-0978
US

V. Phone/Fax

Practice location:
  • Phone: 770-813-0087
  • Fax: 770-813-9006
Mailing address:
  • Phone: 770-813-0087
  • Fax: 770-813-9006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: