Healthcare Provider Details

I. General information

NPI: 1104924877
Provider Name (Legal Business Name): GREG R BURTON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 E MAIN ST STE 331
LOVELL WY
82431-2004
US

IV. Provider business mailing address

PO BOX 395
LOVELL WY
82431-0395
US

V. Phone/Fax

Practice location:
  • Phone: 307-887-6202
  • Fax: 702-474-7458
Mailing address:
  • Phone: 307-887-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT768
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3193
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: