Provider Demographics
NPI:1477055226
Name:BECKER, SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:BECKER
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 1:300 S LENOLA RD
Mailing Address - Street 2:# 23
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-3435
Mailing Address - Country:US
Mailing Address - Phone:856-733-0684
Mailing Address - Fax:
Practice Address - Street 1:300 S LENOLA RD
Practice Address - Street 2:# 23
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-3435
Practice Address - Country:US
Practice Address - Phone:856-733-0684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-07
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00750600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor