Provider Demographics
NPI:1316219223
Name:BURT, ALLEN DOUGLAS (CR)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:DOUGLAS
Last Name:BURT
Suffix:
Gender:M
Credentials:CR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-2951
Mailing Address - Country:US
Mailing Address - Phone:708-672-4773
Mailing Address - Fax:
Practice Address - Street 1:1397 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2951
Practice Address - Country:US
Practice Address - Phone:708-672-4773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist
No175F00000XOther Service ProvidersNaturopath