Healthcare Provider Details

I. General information

NPI: 1730611856
Provider Name (Legal Business Name): JON BURZACOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 ORIOLE CT
TIFFIN IA
52340
US

IV. Provider business mailing address

329 ORIOLE CT
TIFFIN IA
52340-9383
US

V. Phone/Fax

Practice location:
  • Phone: 319-430-8853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number00666
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: