Provider Demographics
NPI:1215473871
Name:SHADE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:SHADE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-751-9500
Mailing Address - Street 1:43 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07727-1340
Mailing Address - Country:US
Mailing Address - Phone:732-751-9500
Mailing Address - Fax:732-751-9516
Practice Address - Street 1:43 MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NJ
Practice Address - Zip Code:07727
Practice Address - Country:US
Practice Address - Phone:732-751-9500
Practice Address - Fax:732-751-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00554600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty