Provider Demographics
NPI:1689637746
Name:BURCH, DELEON JAMAAL (PT)
Entity Type:Individual
Prefix:
First Name:DELEON
Middle Name:JAMAAL
Last Name:BURCH
Suffix:
Gender:M
Credentials:PT
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 6526
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29260-6526
Mailing Address - Country:US
Mailing Address - Phone:803-693-5040
Mailing Address - Fax:803-993-9472
Practice Address - Street 1:148 SAULS ST STE B
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2677
Practice Address - Country:US
Practice Address - Phone:843-374-0185
Practice Address - Fax:843-374-0189
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9364225100000X
GAPT008466225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA591304637BMedicaid
GA591304637CMedicaid
GA591304637AMedicaid
GA65BBFCNMedicare PIN