Provider Demographics
NPI:1306396395
Name:BURKE, IRA
Entity Type:Individual
Prefix:
First Name:IRA
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 1:1480 HAMMOCK RIDGE RD
Mailing Address - Street 2:6106
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6378
Mailing Address - Country:US
Mailing Address - Phone:352-801-5901
Mailing Address - Fax:
Practice Address - Street 1:1480 HAMMOCK RIDGE RD
Practice Address - Street 2:6106
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6378
Practice Address - Country:US
Practice Address - Phone:352-801-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5207357314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility