Provider Demographics
NPI:1164672259
Name:BURKS, JOHN PAUL (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PAUL
Last Name:BURKS
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 1:91B 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1948
Mailing Address - Country:US
Mailing Address - Phone:850-200-7178
Mailing Address - Fax:
Practice Address - Street 1:151 MARY ESTHER BLVD
Practice Address - Street 2:STE 307A
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1972
Practice Address - Country:US
Practice Address - Phone:850-200-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50049225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist