=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215202254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOBBY MICHAEL BURKE PEER NAVIGATOR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2012
-----------------------------------------------------
Last Update Date | 02/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 WILSHIRE BLVD 500
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90057-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-639-0254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10971 CHALON RD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90077-3218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-994-2924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------