Healthcare Provider Details

I. General information

NPI: 1184783458
Provider Name (Legal Business Name): JEREMIAH LUKE BURSCH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 2ND AVE S
SAUK RAPIDS MN
56379-1408
US

IV. Provider business mailing address

12 2ND AVE S
SAUK RAPIDS MN
56379-1408
US

V. Phone/Fax

Practice location:
  • Phone: 320-257-6008
  • Fax: 320-257-6009
Mailing address:
  • Phone: 320-257-6008
  • Fax: 320-257-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4107
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: