Healthcare Provider Details

I. General information

NPI: 1558726448
Provider Name (Legal Business Name): MIKE BURGGRAF M.S., L-ATC, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 S 100 E
MANTUA UT
84324
US

IV. Provider business mailing address

PO BOX 800
BRIGHAM CITY UT
84302-0800
US

V. Phone/Fax

Practice location:
  • Phone: 435-720-1321
  • Fax:
Mailing address:
  • Phone: 435-720-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number070302009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: