Healthcare Provider Details

I. General information

NPI: 1710231352
Provider Name (Legal Business Name): MR. JOHN DUANE BURNS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EAGLE FEATHERS DRIVE
LAME DEER MT
59043
US

IV. Provider business mailing address

PO BOX 404
LAME DEER MT
59043-0404
US

V. Phone/Fax

Practice location:
  • Phone: 406-477-6381
  • Fax: 406-477-6727
Mailing address:
  • Phone: 406-477-6381
  • Fax: 406-477-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11-118
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: