MEDICARE: DR. BRUCE DAVID BECKER D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	0104000521	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40177	OTHER		MAMSI INS CO.

General Provider Information

NPI Number	:	1174623672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE DAVID BECKER D.C.

Provider Business Mailing Address
First Line	:	11862 SUNRISE VALLEY DR
Second Line	:	SUITE 101
City	:	RESTON
State	:	VA
Zip	:	20191-3302
Country	:	US
Telephone Number	:	703-620-5808
Fax Number	:

Provider Business Practice Location Address
First Line	:	11862 SUNRISE VALLEY DR
Second Line	:	SUITE 101
City	:	RESTON
State	:	VA
Zip	:	20191-3302
Country	:	US
Telephone Number	:	703-620-5808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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