MEDICARE: KEITH BURNETTE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	1041C0700X	Clinical Social Worker	OH
2	172V00000X	Community Health Worker
3	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1629841143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH BURNETTE

Provider Business Mailing Address
First Line	:	1940 TONAWANDA AVE
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44305-3657
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1768 GOODYEAR BLVD
Second Line	:
City	:	AKRON
State	:	OH
Zip	:	44305-2953
Country	:	US
Telephone Number	:	330-957-5114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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Directions to “ KEITH BURNETTE ” Practice Location

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