=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013194281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CURTIS D. BURGHART, OD, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2008
-----------------------------------------------------
Last Update Date | 11/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1203 S GOLD ST
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-4203
-----------------------------------------------------
Fax | 360-736-7059
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1203 S GOLD ST
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98531-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-736-4203
-----------------------------------------------------
Fax | 360-736-7059
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CURTIS DEAN BURGHART
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 360-736-4203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1838
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------