Provider Demographics
NPI:1710521877
Name:MONROE, SHANE DAVID
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DAVID
Last Name:MONROE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 ARIANNA ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3050
Mailing Address - Country:US
Mailing Address - Phone:707-342-7333
Mailing Address - Fax:
Practice Address - Street 1:3355 EAGLE PARK DR NE STE 108
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7004
Practice Address - Country:US
Practice Address - Phone:707-342-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000225171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist