Provider Demographics
NPI:1619479276
Name:BURGESS FAMILY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BURGESS FAMILY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHABON
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-933-9024
Mailing Address - Street 1:508 E WILSON ST
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764-9115
Mailing Address - Country:US
Mailing Address - Phone:580-933-9024
Mailing Address - Fax:580-933-9027
Practice Address - Street 1:508 E WILSON ST
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764-9115
Practice Address - Country:US
Practice Address - Phone:580-933-9024
Practice Address - Fax:833-382-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QP2300X
293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No293D00000XLaboratoriesPhysiological Laboratory