Provider Demographics
NPI:1932249869
Name:BURT CLINIC OF CHIROPRACTIC PC
Entity Type:Organization
Organization Name:BURT CLINIC OF CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-284-6927
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:790 N MAIN ST
Mailing Address - City:WALCOTT
Mailing Address - State:IA
Mailing Address - Zip Code:52773-0790
Mailing Address - Country:US
Mailing Address - Phone:563-284-6927
Mailing Address - Fax:563-284-6398
Practice Address - Street 1:790 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALCOTT
Practice Address - State:IA
Practice Address - Zip Code:52773-9505
Practice Address - Country:US
Practice Address - Phone:563-284-6927
Practice Address - Fax:563-284-6398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04377111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0122689Medicaid
IA0122689Medicaid