Provider Demographics
NPI:1477834711
Name:BURGENER, CLINT REX (LMP)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:REX
Last Name:BURGENER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53495 E BALLOU RD
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862-7400
Mailing Address - Country:US
Mailing Address - Phone:701-263-7094
Mailing Address - Fax:
Practice Address - Street 1:20 E POPLAR ST STE 206
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3099
Practice Address - Country:US
Practice Address - Phone:509-527-1156
Practice Address - Fax:509-522-4933
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60237216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist