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General NPI Number Information
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NPI Number | 1336340314
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Entity Type | Organization
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Legal Business Name | SHADOW MOUNTAIN CHIROPRACTIC CLINIC PC
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 60 SECOND ST
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City | GRANBY
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State | CO
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Zip | 80446-0036
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Country | US
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Telephone | 970-887-3131
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Fax | 970-887-3913
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Provider Business Mailing Address
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Address Line | PO BOX 36
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City | GRANBY
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State | CO
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Zip | 80446-0036
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Country | US
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Telephone | 970-887-3131
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Fax | 970-887-3913
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY W SHAW
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Credential | D. C.
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Telephone | 970-887-3131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1596
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License Number State | CO
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