=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124284252
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURKE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2008
-----------------------------------------------------
Last Update Date | 07/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 SHADRACK ST
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-1540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-554-9334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 SHADRACK ST
-----------------------------------------------------
City | WAYNESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30830-1540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-554-9334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | DR. CHRISTOPHER JOHN BUNN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 706-554-9334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIRO08351
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------