=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225166036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BURT CHIROPRACTIC PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15200 HESPERIAN BLVD STE 104
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94578-3955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-481-2225
-----------------------------------------------------
Fax | 866-501-8083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15200 HESPERIAN BLVD STE 104
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94578-3955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-481-2225
-----------------------------------------------------
Fax | 866-501-8083
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. EDUARD BURT
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 510-481-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-28211
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------