Provider Demographics
NPI:1497376586
Name:BURCH, SAMANTHA ROSE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ROSE
Last Name:BURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32430 STATE HIGHWAY 123
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-3059
Mailing Address - Country:US
Mailing Address - Phone:218-341-8861
Mailing Address - Fax:
Practice Address - Street 1:1602 HIGHWAY 23 N
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5009
Practice Address - Country:US
Practice Address - Phone:320-216-4150
Practice Address - Fax:320-216-4101
Is Sole Proprietor?:No
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker