Healthcare Provider Details

I. General information

NPI: 1699153775
Provider Name (Legal Business Name): LISA BURKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4026 ASHLEY PHOSPHATE RD
CHARLESTON SC
29418-8547
US

IV. Provider business mailing address

6520 DORCHESTER RD APT 400G
NORTH CHARLESTON SC
29418-5140
US

V. Phone/Fax

Practice location:
  • Phone: 843-730-0186
  • Fax:
Mailing address:
  • Phone: 843-730-0186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberIRC. 35076
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: