Healthcare Provider Details

I. General information

NPI: 1790840262
Provider Name (Legal Business Name): RICHARD JOSHUA BURNS CCP LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 S HIGHWAY 76
NEWCASTLE OK
73065
US

IV. Provider business mailing address

PO BOX 1378
NEWCASTLE OK
73065
US

V. Phone/Fax

Practice location:
  • Phone: 405-392-3628
  • Fax: 405-392-2137
Mailing address:
  • Phone: 405-392-3628
  • Fax: 405-392-2137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberLP5
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: