Provider Demographics
NPI:1083235733
Name:BURGESS, LARRY ALDEN (LMT)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALDEN
Last Name:BURGESS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 NE 102ND ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64156-2914
Mailing Address - Country:US
Mailing Address - Phone:816-666-5511
Mailing Address - Fax:
Practice Address - Street 1:208 NE BARRY RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2722
Practice Address - Country:US
Practice Address - Phone:816-666-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002001790225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist