=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992766562
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFF HOLZWORTH SHAFFER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3960 EXECUTIVE PARK BLVD STE 5
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-454-8100
-----------------------------------------------------
Fax | 910-454-8101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3960 EXECUTIVE PARK BLVD STE 5
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-454-8100
-----------------------------------------------------
Fax | 910-454-8101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2905
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------