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General NPI Number Information
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NPI Number | 1710988068
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Entity Type | Organization
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Legal Business Name | SHALLOW CHIROPRACTIC PC
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Dates
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Enumeration Date | 08/09/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 24820 MICHIGAN AVE
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City | DEARBORN
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State | MI
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Zip | 48124-1713
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Country | US
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Telephone | 313-277-3766
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Fax | 313-277-7196
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Provider Business Mailing Address
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Address Line | 24820 MICHIGAN AVE
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City | DEARBORN
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State | MI
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Zip | 48124-1713
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Country | US
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Telephone | 313-277-3766
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Fax | 313-277-7196
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Authorized Official
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Title or Position | PRESIDENT/DIRECTOR
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Name | MR. RANDY JOE SHALLOW
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Credential | DC
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Telephone | 313-277-3766
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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 | 2301004116
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License Number State | MI
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