Healthcare Provider Details

I. General information

NPI: 1730455874
Provider Name (Legal Business Name): MR. KIRBY LEE BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 RENAISSANCE DR STE A
LAS VEGAS NV
89119-6191
US

IV. Provider business mailing address

PO BOX 81134
LAS VEGAS NV
89180-1134
US

V. Phone/Fax

Practice location:
  • Phone: 702-739-7716
  • Fax: 702-597-2242
Mailing address:
  • Phone: 702-303-7907
  • Fax: 702-982-6836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: