Provider Demographics
NPI:1558726448
Name:BURGGRAF, MIKE (MS, L-ATC, EMT)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:BURGGRAF
Suffix:
Gender:M
Credentials:MS, L-ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-0800
Mailing Address - Country:US
Mailing Address - Phone:435-720-1321
Mailing Address - Fax:
Practice Address - Street 1:495 S 100 E
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:UT
Practice Address - Zip Code:84324
Practice Address - Country:US
Practice Address - Phone:435-720-1321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT070302009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist