1194921510 NPI number — SHULL CHIROPRACTIC CLINIC PLLC

Table of content: JENAIJAH JOHNS RECOVERY ASSISTANT (NPI 1679958615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194921510 NPI number — SHULL CHIROPRACTIC CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHULL CHIROPRACTIC CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194921510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 S COLLEGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINCHESTER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37398-2236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-967-4232
Provider Business Mailing Address Fax Number:
931-962-1988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 S COLLEGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINCHESTER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37398-2236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-967-4232
Provider Business Practice Location Address Fax Number:
931-962-1988
Provider Enumeration Date:
06/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHULL
Authorized Official First Name:
KURT
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-967-4232

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3970470 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0146299 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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