1295713832 NPI number — DR. KENNETH D SHELTON D.C.

Table of content: DR. KENNETH D SHELTON D.C. (NPI 1295713832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295713832 NPI number — DR. KENNETH D SHELTON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELTON
Provider First Name:
KENNETH
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1295713832
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1114 DIXIE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSSFORD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-666-1114
Provider Business Mailing Address Fax Number:
419-666-6433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1114 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSSFORD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43460-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-666-1114
Provider Business Practice Location Address Fax Number:
419-666-6433
Provider Enumeration Date:
01/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1163 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02136 . This is a "PARAMOUNT HEALTH CARE ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000133231 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 341520061-003 . This is a "MEDICAL MUTUAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4213864 . This is a "AETNA ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1163 . This is a "LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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