MEDICARE: GEORGIA T BURBULIS LMT

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
1	225700000X	Massage Therapist	011128	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	011128	OTHER	GA	LICENSED MASSAGE THERAPIST

General Provider Information

NPI Number	:	1760935811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIA T BURBULIS LMT

Provider Business Mailing Address
First Line	:	704 WILLOWWIND DR
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-6601
Country	:	US
Telephone Number	:	770-617-3446
Fax Number	:

Provider Business Practice Location Address
First Line	:	6667 VERNON WOODS DR STE B27
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-3216
Country	:	US
Telephone Number	:	770-617-3446
Fax Number	:

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

Provider Enumeration Date	:	07/25/2016
Last Update Date	:	10/17/2019

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