Healthcare Provider Details

I. General information

NPI: 1710521877
Provider Name (Legal Business Name): SHANE DAVID MONROE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 EAGLE PARK DR NE STE 108
GRAND RAPIDS MI
49525-7004
US

IV. Provider business mailing address

1025 ARIANNA ST NW
GRAND RAPIDS MI
49504-3050
US

V. Phone/Fax

Practice location:
  • Phone: 707-342-7333
  • Fax:
Mailing address:
  • Phone: 707-342-7333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5401000225
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: