Provider Demographics
NPI:1881831139
Name:BURTON, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BURTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 E DAKOTA RD
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-9723
Mailing Address - Country:US
Mailing Address - Phone:520-803-0365
Mailing Address - Fax:
Practice Address - Street 1:5840 E DAKOTA RD
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-9723
Practice Address - Country:US
Practice Address - Phone:520-803-0365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11782385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AS00000000000Medicaid