Provider Demographics
NPI:1083250856
Name:BURKE, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E STONE ST
Mailing Address - Street 2:
Mailing Address - City:STURGEON
Mailing Address - State:MO
Mailing Address - Zip Code:65284-8907
Mailing Address - Country:US
Mailing Address - Phone:573-687-3012
Mailing Address - Fax:573-687-3305
Practice Address - Street 1:315 E STONE ST
Practice Address - Street 2:
Practice Address - City:STURGEON
Practice Address - State:MO
Practice Address - Zip Code:65284-8907
Practice Address - Country:US
Practice Address - Phone:573-687-3012
Practice Address - Fax:573-687-3305
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility