Provider Demographics
NPI:1770668550
Name:MICHAEL S BURGOON DC PC
Entity Type:Organization
Organization Name:MICHAEL S BURGOON DC PC
Other - Org Name:TOWERS FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURGOON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:540-343-6636
Mailing Address - Street 1:2302 COLONIAL AVE SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015
Mailing Address - Country:US
Mailing Address - Phone:540-343-6636
Mailing Address - Fax:540-343-6670
Practice Address - Street 1:2302 COLONIAL AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015
Practice Address - Country:US
Practice Address - Phone:540-343-6636
Practice Address - Fax:540-343-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001967111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA292833OtherANTHEM
P00008229OtherPALMETTO MEDICARE
VA292833OtherANTHEM
C08630Medicare ID - Type UnspecifiedGROUP