Provider Demographics
NPI:1679965248
Name:SHELLY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:SHELLY CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SHELLY
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:985-400-1633
Mailing Address - Street 1:17534 OLD JEFFERSON HWY
Mailing Address - Street 2:SUITE C2
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3978
Mailing Address - Country:US
Mailing Address - Phone:985-400-1633
Mailing Address - Fax:
Practice Address - Street 1:17534 OLD JEFFERSON HWY
Practice Address - Street 2:SUITE C2
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3978
Practice Address - Country:US
Practice Address - Phone:985-400-1633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4N628Medicare UPIN