Provider Demographics
NPI:1083023865
Name:BURR, SHANE (LAC)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:BURR
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5200 BABCOCK ST NE STE 201
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4644
Mailing Address - Country:US
Mailing Address - Phone:321-327-8007
Mailing Address - Fax:321-541-9148
Practice Address - Street 1:5200 BABCOCK ST NE STE 201
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4644
Practice Address - Country:US
Practice Address - Phone:321-327-8007
Practice Address - Fax:321-541-9148
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3832171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist