Provider Demographics
NPI:1205908282
Name:BLUMHARDT, SHANNON REED (DC)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:REED
Last Name:BLUMHARDT
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 1:200 E 2ND AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-2255
Mailing Address - Fax:
Practice Address - Street 1:2721 X RAY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7491
Practice Address - Country:US
Practice Address - Phone:704-874-2255
Practice Address - Fax:704-810-7417
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4842111N00000X
CA30606111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO33754014OtherBLUE CROSS BLUE SHIELD ID
MO33754014OtherBLUE CROSS BLUE SHIELD ID
MOU86148Medicare UPIN