Provider Demographics
NPI:1528178357
Name:JEFFREY K SHAW DC PLLC
Entity type:Organization
Organization Name:JEFFREY K SHAW DC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-947-0755
Mailing Address - Street 1:10975 E BREWERY CREEK LANE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-947-0755
Mailing Address - Fax:231-947-1134
Practice Address - Street 1:10975 E BREWERY CREEK LANE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684
Practice Address - Country:US
Practice Address - Phone:231-947-0755
Practice Address - Fax:231-947-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P40650Medicare PIN