Healthcare Provider Details

I. General information

NPI: 1104859057
Provider Name (Legal Business Name): STEVEN EUGENE BURBACK ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6610 N LOVINGTON HWY
HOBBS NM
88240-9120
US

IV. Provider business mailing address

10711 ROSALIE DR
NORTHGLENN CO
80233-3551
US

V. Phone/Fax

Practice location:
  • Phone: 505-392-6561
  • Fax:
Mailing address:
  • Phone: 505-392-0212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number333
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: