Healthcare Provider Details

I. General information

NPI: 1245255686
Provider Name (Legal Business Name): RICKY R BURK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19801 SW 72ND AVE STE 150
TUALATIN OR
97062-8347
US

IV. Provider business mailing address

PO BOX 1506
CHEHALIS WA
98532-0409
US

V. Phone/Fax

Practice location:
  • Phone: 503-691-2283
  • Fax: 503-691-5981
Mailing address:
  • Phone: 360-242-3008
  • Fax: 360-807-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberATI2559
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: