Provider Demographics
NPI:1447640768
Name:SHALLOW, BRAD ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRAD
Middle Name:ALAN
Last Name:SHALLOW
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 TALL PINE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-4828
Mailing Address - Country:US
Mailing Address - Phone:910-231-3457
Mailing Address - Fax:
Practice Address - Street 1:120 S WOODLAND BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5445
Practice Address - Country:US
Practice Address - Phone:386-341-1404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-24
Last Update Date:2015-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor