Provider Demographics
NPI:1386855179
Name:BURSTON, ALDA M (ATC)
Entity Type:Individual
Prefix:
First Name:ALDA
Middle Name:M
Last Name:BURSTON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9201 UNIVERSITY CITY BLVD
Mailing Address - Street 2:CHARLOTTE ATHLETICS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28223-0001
Mailing Address - Country:US
Mailing Address - Phone:704-687-6926
Mailing Address - Fax:704-687-3944
Practice Address - Street 1:9201 UNIVERSITY CITY BLVD
Practice Address - Street 2:CHARLOTTE ATHLETICS
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28223-0001
Practice Address - Country:US
Practice Address - Phone:704-687-6926
Practice Address - Fax:704-687-3944
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260011312255A2300X
NC15052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer