Provider Demographics
NPI:1811047814
Name:BURDETTE, LAWRENCE WILSON III (DC)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:WILSON
Last Name:BURDETTE
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 FAIRMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-5104
Mailing Address - Country:US
Mailing Address - Phone:304-365-5555
Mailing Address - Fax:304-363-4008
Practice Address - Street 1:618 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5104
Practice Address - Country:US
Practice Address - Phone:304-365-5555
Practice Address - Fax:304-363-4008
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001785Medicaid
WV3810001785Medicaid
WV4151381Medicare PIN