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NPI Code Detail

MEDICARE: MR. BURNETT EUGENE ANCRUM I CASE COORDINATOR

MEDICARE: MR. BURNETT EUGENE ANCRUM I CASE COORDINATOR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225400000XRehabilitation Practitioner

General Provider Information

NPI Number : 1629106562
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BURNETT EUGENE ANCRUM I CASE COORDINATOR
Provider Business Mailing Address
First Line : 1906 W 3RD ST
Second Line :
City : LOS ANGELES
State : CA
Zip : 90057-2304
Country : US
Telephone Number : 323-644-2026
Fax Number : 323-644-2039
Provider Business Practice Location Address
First Line : 340 N MADISON AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90004-3504
Country : US
Telephone Number : 323-644-2026
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/01/2007
Last Update Date : 09/30/2010

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