Provider Demographics
NPI:1003841701
Name:BECKER, GARY L (LMT,DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:BECKER
Suffix:
Gender:M
Credentials:LMT,DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 N WEBER RD
Mailing Address - Street 2:# 379
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-1569
Mailing Address - Country:US
Mailing Address - Phone:630-739-9292
Mailing Address - Fax:630-739-9342
Practice Address - Street 1:8200 JANES AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-4303
Practice Address - Country:US
Practice Address - Phone:630-739-9292
Practice Address - Fax:630-739-9342
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007884111N00000X
OH4864225700000X
ILCERTIFICATE171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002207311OtherBC/BS
IL388940Medicare ID - Type Unspecified