Healthcare Provider Details

I. General information

NPI: 1306224688
Provider Name (Legal Business Name): JOHN BURNSIDE JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 GLADES RD
BOCA RATON FL
33431-6424
US

IV. Provider business mailing address

1200 TALLWOOD AVE 102
HOLLYWOOD FL
33021-7973
US

V. Phone/Fax

Practice location:
  • Phone: 561-297-2044
  • Fax:
Mailing address:
  • Phone: 561-297-3320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 2282
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: