Provider Demographics
NPI:1053451062
Name:BURCIAGA, COYO (PT)
Entity Type:Individual
Prefix:MR
First Name:COYO
Middle Name:
Last Name:BURCIAGA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 N GRAND AVE STE D
Mailing Address - Street 2:PACIFIC CLINICS
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1552
Mailing Address - Country:US
Mailing Address - Phone:626-967-1667
Mailing Address - Fax:626-331-9641
Practice Address - Street 1:1126 N GRAND AVE STE D
Practice Address - Street 2:PACIFIC CLINICS
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-1552
Practice Address - Country:US
Practice Address - Phone:626-967-1667
Practice Address - Fax:626-331-9641
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 30761167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician