Healthcare Provider Details

I. General information

NPI: 1164197885
Provider Name (Legal Business Name): IAN BURFORD CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 08/13/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 E KELLOGG DR
WICHITA KS
67218-1607
US

IV. Provider business mailing address

120 E 1ST ST N APT 6I
WICHITA KS
67202-2044
US

V. Phone/Fax

Practice location:
  • Phone: 316-685-2221
  • Fax:
Mailing address:
  • Phone: 316-641-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO04214
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO04214
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: