Healthcare Provider Details

I. General information

NPI: 1225408487
Provider Name (Legal Business Name): CALEB BURLILE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 STADIUM DR
BOWLING GREEN OH
43403-4302
US

IV. Provider business mailing address

3105 CASPER AVE
HILLIARD OH
43026-9213
US

V. Phone/Fax

Practice location:
  • Phone: 419-372-2401
  • Fax:
Mailing address:
  • Phone: 614-529-8754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: