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General NPI Number Information
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NPI Number | 1649568734
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Entity Type | Organization
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Legal Business Name | SHANNON CHIROPRACTIC WELLNESS LLC
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Dates
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Enumeration Date | 07/11/2011
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Last Update Date | 07/11/2011
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Provider Practice Location Address
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Address Line | 397 KENWOOD AVE
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City | DELMAR
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State | NY
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Zip | 12054-3248
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Country | US
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Telephone | 518-439-1916
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Fax |
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Provider Business Mailing Address
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Address Line | 397 KENWOOD AVE
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City | DELMAR
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State | NY
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Zip | 12054-3248
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Country | US
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Telephone | 518-439-1916
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROGER PHILIP SHANNON
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Credential | D.C.
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Telephone | 518-439-1916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 011939
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License Number State | NY
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