Healthcare Provider Details

I. General information

NPI: 1679217228
Provider Name (Legal Business Name): BURGESS BROTHERS RESTAURANT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 05/20/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6580 BELLEAU WOOD LN
SACRAMENTO CA
95822-5910
US

IV. Provider business mailing address

6580 BELLEAU WOOD LN
SACRAMENTO CA
95822-5910
US

V. Phone/Fax

Practice location:
  • Phone: 916-250-2761
  • Fax:
Mailing address:
  • Phone: 916-250-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN BURGESS
Title or Position: CEO
Credential:
Phone: 916-250-2761