1962632752 NPI number — J.T. BURKE, INC.

Table of content: (NPI 1962632752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962632752 NPI number — J.T. BURKE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
J.T. BURKE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIRACLE-EAR CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962632752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
817 W BROADWAY
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87401-5699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-326-5707
Provider Business Mailing Address Fax Number:
505-326-4026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
817 W BROADWAY
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87401-5699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-326-5707
Provider Business Practice Location Address Fax Number:
505-326-4026
Provider Enumeration Date:
07/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
JAIME
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-326-5707

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X , with the licence number:  0696 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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