Provider Demographics
NPI:1912926650
Name:LANDER, BURGUNDY L (DC)
Entity Type:Individual
Prefix:DR
First Name:BURGUNDY
Middle Name:L
Last Name:LANDER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1405
Mailing Address - Country:US
Mailing Address - Phone:815-518-5228
Mailing Address - Fax:815-634-3188
Practice Address - Street 1:415 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1405
Practice Address - Country:US
Practice Address - Phone:815-518-5228
Practice Address - Fax:815-634-3188
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009357111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5628001Medicare PIN