Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 06404 | IA |
NPI | 1083687545 |
---|---|
Provider Name | Dr. Chad William Burt |
First Address | Walcott, IA 52773-0790 |
Second Address | Walcott, IA 52773-9505 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0122689 | (05) | IA |
U85195 | (02) | IA |