Provider Demographics
NPI:1780734434
Name:BURDETTE FAMILY CHIROPRACTIC AND WELLNESS CENTER, INC.
Entity type:Organization
Organization Name:BURDETTE FAMILY CHIROPRACTIC AND WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:BURDETTE
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:304-363-4006
Mailing Address - Street 1:307 CLEVELAND AVE.
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554
Mailing Address - Country:US
Mailing Address - Phone:304-363-4006
Mailing Address - Fax:304-363-4008
Practice Address - Street 1:307 CLEVELAND AVE.
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554
Practice Address - Country:US
Practice Address - Phone:304-363-4006
Practice Address - Fax:304-363-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7028671OtherAETNA
WV38100001785Medicaid
WV7028671OtherAETNA
WV38100001785Medicaid