Provider Demographics
NPI:1720403488
Name:IRVIN, BURNEY IV (CRT)
Entity Type:Individual
Prefix:
First Name:BURNEY
Middle Name:
Last Name:IRVIN
Suffix:IV
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-6322
Mailing Address - Country:US
Mailing Address - Phone:909-821-5111
Mailing Address - Fax:909-986-2545
Practice Address - Street 1:2002 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-6322
Practice Address - Country:US
Practice Address - Phone:909-821-5111
Practice Address - Fax:909-986-2545
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26804227800000X, 2278E1000X, 2278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278E1000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedEducational
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
No2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health